Threats Against Clinicians: A

Preliminary Descriptive
Classification
Gregory P. Brown, MD, William R. Dubin, MD, John R. Lion, MD, and
Leonard J. Garry, MD

Threats against psychiatrists are common, but existing studies on the subject lack
descriptive information about the nature and resolution of the threat. In the
present study, clinicians who had received threats were interviewed in person or
by telephone, and case histories were summarized. Threats were classified as
situational and transferential. Demographic factors, precipitating events, and legal
actions taken are described. The manner in which clinicians reacted to threats is
also discussed.

"No physician, however conscientious or few clinical studies. ~ i l l e r surveying

.~
careful. can tell what day or hour he may forensic psychiatrists who reported hav-
not be made the object of some unde- ing been harassed, found that 42 percent
served attack, malicious accusation, of the sample had been threatened. while
blackmail, or suit for damages. . . . " I only 3 percent had actually been as-
Since this observation was published in saulted. erns stein,' reporting on verbal
1892, threats against clinicians remain threats made on mental health practition-
ubiquitous. Yet the nature of the threats is ers, found that 20 patients threatened a
the subject of limited research and of only fight, 16 patients threatened to shoot with
-
-
a gun, 7 patients threatened to assault
Dr. Brown, formerly a resident at Albert Einstein Med- with a knife, and 7 patients threatened
ical Cenlcr, Philadelphia, PA and a forcnsic fellow in
psychiatry at the University of Rochester, Rochester, assault with an office object. ~aulkner,"
NY, is currently Assistant Professor of Clinical Psychi-
atry at the University of Nevada School of Mcdicine,
analyzing threats on psychiatrists. found
Las Vegas, NV. Dr. Dubin is acting medical director, that 45 threats were written, 91 were ver-
Relmont Center for Comprehensive Treatment, and pro-
fessor of psychiatry, Temple University, Philadelphia, bal, 52 were delivered over the telephone,
PA. Dr. Lion is clinical professor of psychiatry, Univel-- and 5 via a third person.
sity of Maryland School of Medicine, Baltimore, MD.
Dr. Garry, formerly a resident at A l b e ~Einstein
t Medical With the exception of ~ i 1 l e r . sstudy
~
Center, is currently in private practice in New Jersey and of forensic psychiatrists, these studies
is affiliated with the Belmont Center for Comprehensive
Treatment, Philadelphia, PA. Address correspondence lack descriptive information concerning
to: Gregory P. Brown, MD, Southern Nevada Adult the threats, thus making it difficult to
Mental Health Services, 6161 West Charleston, Blvd.,
Las Vegas, NV 89158. understand how and in what context the

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 367

 Brown, Dubin, Lion, etal.

threats occurred. These studies do not de- therapeutic relationship existed between
scribe how patients' threats are managed the patient and the clinician. Situational
and ultimately resolved. And finally. threats occurred in clinical situations in
there is no classification system that al- which the psychiatrist happened to be
lows a more systematic approach to the present either as an administrator. or as a
study and understanding of the threat sit- clinician momentarily caring for the pa-
uation. To address these issues, the au- tient, in a setting such as a general psy-
thors undertook to examine in more detail chiatric ward or an emergency room.
threats that took place in clinical practice While transference may play a role in the
settings. Our current study describes 19 situational threat, the predominant char-
cases of threats against clinicians. Based acteristic is the denial of a wish by the
on these cases, a preliminary classifica- clinician with the immediate response, a
tion of threats will be proposed. threat, by the patient. Examples of situa-
tional threats are presented in Appendix I.
Methods In contrast, transferential threats usually
Clinicians who were known to have occurred during an ongoing psychothera-
been threatened in the past and who con- peutic relationship, most often in an out-
sented to discuss their experiences were patient setting. The patients appeared to
interviewed by telephone or in person. react to their therapists as a function of
For the purposes of this study. threats the intimacy inherent in the treatment par-
were defined as any hostile statement or adigm. Transference-related threats, in
action that fell short of physical contact retrospect, generally appeared to evolve
with the clinician involved. The clinicians slowly and insidiously, even though there
were identified in two ways: first. from was often a precipitating event for the
workshops conducted by the American utterance of the actual threatening re-
Psychiatric Association's Task Force on mark. Examples of transferential threats
Clinician Safety at several annual meet- are presented in Appendix 11
ings; and second, from private cases Demographics Table 1 describes the
brought to the attention of the authors data for 10 threats of the situational type
(J.R.L. and W.R.D.). Sixteen cases in- and 9 threats of the transferential type.
volved psychiatrists or psychiatric resi- The average age of the clinician is ap-
dents, two cases involved surgeons, and proximately the same in both categories.
one case involved a clinical psychologist. Residents appear to be equally likely to
All case histories are summarized in the be the object of either category of threat.
appendices. Patient data for threats indicated a
slightly older age of patient for the situ-
Results ational threat when compared with the
Types of Threats We found that transferential threat and a high predomi-
threats could be classified roughly into nance of male patients who became
two types: the situational threat and the threatening. The diagnostic groups
transferential threat. based on whether a present for both types of threat are psy-

368 Bull Am Acad Psychiatry Law, Vol. 24, No. 3,1996

Threats Against Clinicians

Table 1
Threat Overview Data
Total Threats Situational Transferential
n = 19 n = 10 n=9
Average clinician age 40
Clinician male:female 11:8
Incident when resident 6
Prior training in aggression management 4
Threatened or assaulted on other occasion 9

Average patient age

Patient male:female
Psychotic disorder
Personality disorder
Known substance abuse

Legal action taken or attempted 8

Precipitating event
Weapon used

Change in professional life

Change in personal life

chotic disorders and personality disor- the therapist stating that she would be
ders. with substance abuse being present moving out of the state. the therapist fall-
as a secondary diagnosis only in the in- ing asleep during a session, dissociative
patient subset of situational threats. state of the patient. the patient's being
Precipitating Events A precipitating discharged from a clinic against his
event was identified by the practitioner in wishes, the psychiatrist missing a therapy
all 10 of the situational threats and in 6 of session, and too intense a closeness in the
the transferential threats. Each situational transference.
threat involved a precipitating event: Weapons The only two cases in
these included refusal of discharge or ad- which a weapon was involved were both
mission, refusal to endorse a report of classified as transferential-type threats,
disability, suggesting the patient take a and both involved guns. One of the cases
medication that the patient did not want, involved firing a shot through the window
testifying that the patient was unable to of the clinician's house (case T3). The
manage his funds, and refusal to give a other case of a patient wielding a gun was
copy of the patient's records to her. Six of in an outpatient clinic where the psychi-
the nine transferential threats involved a atrist was held at gunpoint for seven min-
specific precipitating event that included utes (case T8). Neither of the clinicians in

Bull Am Acad Psychiatry Law, Vol. 24, No. 3,1996 369

 Brown, Dubin, Lion, eta/.

either of these cases was injured. In the patient. The changes reported for situa-
one case in which a clinician was hurt, the tional threats included taking a more thor-
threats escalated into an assault when the ough history of violent behavior, refusing
patient pushed and hit the clinician (case to do future disability evaluations, carry-
S7). ing a portable alarm during interviews,
Legal Action Legal action (filing for- having security provide an escort to the
mal charges) was taken or attempted fol- car while on hospital grounds. attempting
lowing five of the transferential threats to be less confrontational in therapy, and
and three of the situational threats. In two generally being more cautious. Changes
of these cases, either police or attorneys reported after transferential threats in-
indicated to the clinician that there was cluded keeping more therapeutic dis-
insufficient evidence to file charges, al- tance, reducing the number of therapy
though the clinician expressed interest in patients, having alarm systems installed
doing so. In another case, the state's at- in the office, hiring an answering service
torney had a threatening patient in a state to take phone calls, learning techniques to
hospital moved to another unit after state adequately intervene with violent pa-
hospital staff refused to do so. The diffi-
tients, performing a more thorough as-
culty of seeking prosecution was men-
sessment of the patient's potential for vi-
tioned by several clinicians.
olence, carrying mace, changing the
In ongoing threats, involven~entof the
phone number to an unlisted number, re-
legal system did not provide the relief that
questing police patrol of the neighbor-
the clinicians had expected. In one o f
hood, and hiring a detective. This type of
these cases, the patient was informed by
threat created intense family stress for the
the Federal Bureau of Investigation (FBI)
that it was illegal to write threatening clinicians, some of whom felt they had
letters. After receiving this warning, the "failed" their families, and added restric-
patient began to write threats on the out- tions on family activities because of in-
side of the envelope, which were then creased security measures.
considered too vague for prosecution. In Content of Threat Table 2 examines
another case, the patient was given pro- details surrounding each threat. The
bation because of a mental health history, means of communicating the threat in-
which upset the clinician, who felt that cluded direct verbal communication, tele-
for her safety the patie& should have phone calls, physical action or agitation.
been incarcerated. In another case, the letters, and verbal comn~unication by
clinician was shocked to be told by police means of a third party. The content of the
and the FBI that she was unreliable and threats included death, assault. sexual as-
must be fabricating at least some aspects sault, defamation, harm to the clinician's
of the incident. family members, and revenge. Whereas
Life Changes A total of 14 clinicians threats of death and assault are most com-
made changes in their professional or per- mon in both categories of threat, threats
sonal lives after being threatened by a of revenge, harm to family members and

370 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996

Threats Against Clinicians

Table 2
Threat Details
Total Situational Transferential
Means of communicating threat
Verbal 7
Phone calls 4
Physical action 6
Letters 5
Via third party 1
Content of verbal threat
Death 9
Assault 5
Sexual assault 2
Defamation 2
Harm family 1
Revenge 1
Resolution
Resolved threats 16
Unresolved threats 3
Resolved threats: means of resolution
Patient actually assaulted clinician 1
Patient made no further contact 2
Legal action 4
Administrative/security discharge 3
Hospitalization/medication 2
Confrontation in therapy 1
Doctor removed self from setting 2
Gave patient more control in interview 1
Unresolved threats: attempted means of resolution
Legal action 3
Moved to new location 3"
Security systems 2
Patient referred to other provider 3"
a In one case this was the precipitating factor.

defamation were limited to the transfer- Discussion

ential type threat. Types of Threats We have divided
Resolution of Threats The majority threats into two categories: situational
(16) of the threats eventually ceased, 10 and transferential. In a situational threat,
of these being situational and 6 transfer- patients are responding to the denial of a
ential. All three unresolved threats (cases wish, the precipitant is readily identified,
T2, T3. and T9) are of the transferential and the threat is usually resolved with
type. In the cases of unresolved threats, immediate intervention. In contrast, a
all three clinicians moved to new houses, transferential threat occurs against a cli-
referred the patient to another provider, nician who is actively involved in the
and took legal action against the patient, treatment and may result from a distorted
all to no avail. transference. While situational threats

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 371

 Brown, Dubin, Lion, etal.

usually occur in a hospital or emergency threats that came to our attention. but also
department setting, the transferential by their intensity and dangerousness.
threat usually occurs in an outpatient set- The resolution of threats requires that
ting. In the situational threat. the clinician the clinician acknowledge the threat and
is usually treating the patient only for the then consider appropriate action. As such,
circumscribed time that he or she is in the threats represent urgent pleas for attention
hospital setting. Most of the transference on the part of the patient: unheeded, such
threats occurred against a psychiatrist statements may increase in intensity.
who was involved in ongoing psychother- Confrontation of the threatener is usually
apy with the patient. necessary. Statements such as "you're
Transferential threats were much more scaring me with your threats" can, if ap-
disruptive to psychiatrists' personal lives propriate, defuse a dangerous situation.
and had a direct impact on their families. The setting of firm limits in an outpatient
The transferential threats seemed to be setting has been described by ~ i l l o w i t z ~
more protracted and difficult to resolve as important in resolving a transference-
and were the only category of threats that related threat. and the use of multiple
remained unresolved. Yet while these staff to dilute a dangerous transference
threats were disruptive, intrusive, and has been described by ~ichmond."
frightening to the psychiatrist. no one was Situational threats resolve quickly once
actually injured in this threat category. the situation has changed (commitment
Management of Threats A major im- completed, patient discharged, patient
pediment to the successful management transferred to another service, medication
of threats appears to be the psychological given) through clinical intervention. Sug-
defense of denial. The clinicians who gestions for reducing this type of threat
were the victims in those cases that were are to use a calm interpersonal style to
chronic and lasted for years exhibited reduce the chance that patients will re-
emotions ranging from persistent anxiety spond to external cues such as tone of
to detachment and indifference. In the voice; involve the treatment team in in-
latter instance. denial seemed to play a forming patients of decisions likely to be
large role and enabled the therapists to seen as refusals, to dilute the threat
ignore the threat and continue their work. among many staff; and give patients as
~ u b i nfound
~ that of 59 percent of the much control over their situation as pos-
psychiatrists who continued to see a pa- sible, so that they will not find a threat (or
tient who had assaulted them, 2 l percent assault) the only means of reasserting
did not discuss the attack with the patient. their power.
The negative effect of such denial on the Transferential threats may take a long
potential escalation of violence has been time to resolve because of the intense
described by both ion^ and the Ameri- emotions engendered by the therapeutic
can Psychiatric Association's Task Force process. Due to the possible difficulty of
on Clinician safety.' We were surprised resolving this type of threat. it is impor-
by not only the chronicity of some of the tant that transference be monitored

372 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996

Threats Against Clinicians

transference and countertransference are of alcoholism was not improving on medication.

described elsewhere. "'. ' In instances i n
After he was refused discharge by the treating
resident psychiatrist, he contained his anger until
which threats do not recede with time and he was off the unit and then threw a ceramic object
intervention. termination of treatment alld at another patient. After being escorted to the
seclusion room by staff members, he yelled at the
even prosecution may be necessary."~
psychiatrist "I'm going to kill you, bitch." The
The slna'l number of cases i n this re- attending psychiatrist decided to discharge the pa-
port make our proposed classification tient because the patient repeated his threats the
highly preliminary. As our database of next day. The patient was escorted out of the
hospital by security personnel and was placed on
threat events increases, we hope to be the hospital's "do not admit" list. He has had no
able to determine whether the two cur- contact with either doctor since discharge, al-
rently proposed categories are adequate though it is believed he may have called the nurs-
and accurate. ing station occasionally.
S3. A 50-year-old male with a history of bipolar
The prevention of threats and assaults disorder and cocaine and alcohol abuse was unco-
remains problematic in clinical practice. operative with the evaluation in the medical emer-
The American Psychiatric Association gency room. A psychiatric consultation was ob-
tained on this patient, who was well known to the
Task Force Report on Clinician safety7
psychiatric emergency service. When the psychi-
has reviewed some steps therapists can atrist noticed alcohol on the patient's breath, she
take to make the workplace safer, and told the patient to leave, as per the treatment
other authors have suggested such inter- contract that had been previously established with
this patient. The patient exploded and stated "It's
ventions as to preserve a your life lady, and it's over." Security personnel
therapeutic mileu. Health-care work were called to escort the paticnt out of the hospital.
safety is becoming increasingly recog- Charges were filed against the patient for "terror-
nized as important.'"he classification istic threatening," and he is no longer allowed on
the grounds of that hospital. There were no further
and understanding of threats and assaults threats from this patient.
is a step toward controlling the dangers of S4. A 36-year-old male with a diagnosis of
hospital and outpatient work. antisocial personality, alcohol dependence, and
explosive personality disorder called his inpatient
treating psychiatrist and threatened to kill him
Appendix I. Situational Threats after the patient was discharged from the hospital
at the patient's request. The threat resolved spon-
S l . A 26-year-old male diagnosed with schizo- taneously, since the patient never contacted the
phrenia felt that he was ready to leave the hospital. clinician again.
When his treating psychiatrist explained that she S5. A male in his mid-thirties was diagnosed as
did not think that he was ready for discharge, he malingering by the neurosurgeon who was evalu-
threatened to rape and kill her. Later the patient ating him for a disability claim. After leal-ning that
apologized, but this pattern of threat and apology disability had been denied, the patient came to the
was repeated over several months. The doctor office demanding to see the clinician, threatening
initially ascribed the threatening behavior to psy- to kill him. The doctor left the office by a rear exit.
chosis and believed i t would resolve after mcdi- After being told that the doctor was not in the
cation therapy. When it became clear that the office, the patient walked out and never returned to
threats were going to continue, the patient was the office or threatened this clinician again.
transferred to another service, and the physician S6. A 28-year-old male with a diagnosis of
received no further threats from the patient. schizophrenia agreed to be interviewed in front of
S2. A 25-year-old male with a diagnosis of a class of medical students. He responded to the

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 373

 Brown, Dubin, Lion, et a/.

senior psychiatrist's question of what had hap- facility. There was no further contact with the
pened to his mother prior to his admission with patient.
"do you want me to punch you in the face?'The
clinician gave more control by stating that he did Appendix It. Transferential Threats
not want to be hit and then by asking what the
patient would like to talk about. The interview TI. A male in his thirties with a diagnosis of
proceeded uneventfi~lly,and the patient was re- borderline personality disorder was in therapy for
turned to the inpatient unit and made no further over a year. During a psychotherapy session, the
threats. psychiatrist fell asleep, after which the patient
S7. A 17-year-old female diagnosed with bor- angrily left the office. The psychiatrist invited the
derline personality disorder and rage attacks phys- patient back to discuss what had happened. After
ically threatened her psychiatrist during the second the discussion, the psychiatrist apologized. The
medication evaluation visit after he refused to give patient responded by smashing a clock on the
her her medical records. When they proceeded to floor. The psychiatrist indicated that in order to
the director's office to discuss her complaint, she continue treatment the patient would have to talk
blocked the exit from the room with her person for about his feelings and not act on them. The patient
both him and the clinic director. She bit the direc- agreed, but at the next session brought cans of
tor and pushed the clinician, mildly injuring his black paint and began opening them and throwing
elbow. The director called the police, who arrived them at the office furnishings. The patient was
and restrained the patient within minutes. Legal involuntarily committed, during which time he left
charges were brought against the patient; although messages on the psychiatrist's answering machine
a conviction was not obtained, the judge ordered stating that he would "get him," and sent letters
that the patient never return to that psychiatric saying "kill." A restraining order was delivered to
clinic again. the patient by the police and after three months all
S8. A 47-year-old male diagnosed with schizo- threats stopped. This clinician had no further con-
phrenia threatened a psychiatrist who offered him tact with this patient.
medication. He stated that he didn't need niedica- T2. A 38-year-old bisexual female with a diag-
tion and shook his fist at the clinician. The pa- nosis of depression and borderline personality had
tient's wife, who was in the office, held the patient been in therapy with the psychiatrist for several
away from the clinician and took a prescription for years. This patient had been refused treatment by
the patient. The patient was hospitalized the next many other psychiatrists in the community, and
day and later apologized to the clinician. her initial question to this doctor was "will you
S9. A male in his mid-forties with a diagnosis always be my doctor?'After the doctor notified
of alcoholism threatened to assault the psychiatrist her that she would be moving to another part of the
after being refused admission to the hospital. Se- country, the patient began threatening the doctor
curity personnel removed the patient from the with letters, telephone calls, and photographs of
hospital grounds, and the patient made no further targets. These events occurred even after the psy-
contact with the doctor. chiatrist moved. The patient would come to the
SIO. The patient was a 44-year-old male with a doctor's house and leave paint on the driveway
diagnosis of schizophrenia. The patient was not and around the house. The patient took legal
scheduled to see the psychiatrist, but one month courses after the psychiatrist moved and then filed
after the psychiatrist testified in a court hearing a suit against the psychiatrist and sent allegations
that the patient was unable to handle financial of ethical violations to the state medical board, in
affairs, the patient destroyed the psychiatrist's of- addition to writing letters to the doctor and her
fice, breaking windows and bookcases. The psy- husband's new office colleagues claiming they
chiatrist was in the next room and heard his office had HIV. The patient also threatened to hurt the
being destroyed. Police were called to restrain the psychiatrist's children, and threatened to car-bomb
patient, who was later involuntarily committed to the psychiatrist. Although the frequency of the
the hospital. Legal charges were filed, but district threats has declined over the past four years, the
attorneys stated that they were too busy to prose- threats do continue. Legal recourse has been un-
cute a "misconduct" case such as this. The hospital satisfactory, because the doctor says the police and
arranged for the patient to receive care in another the FBI stated to her that she was making up the

374 Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996

Threats Against Clinicians

incident after a two-year investigation. The psy- state's attorney, who had the patient immediately
chiatrist states that she copes with the situation by moved to another unit.
giving up hope that it will ever end, and by "put- T5. A 46-year-old female with a diagnosis of
ting it in the background." multiple personality disorder threatened her psy-
T3. An 18-year-old male on an inpatient unit chologist only when she was in the personality of
was being treated for schizophrenia while the psy- a 13-year-old boy. The threat was confronted in
chiatrist was in her residency. The patient's con- therapy, with the therapist stating that no one has
dition improved while he was on medication in the to die and that both of them could be safe in
hospital, and he was discharged. Later, the doctor therapy. The frequency of this occurrence has less-
began receiving love letters from the patient, ened, and the clinician believes that the risk of
which she ignored until he broke into her car and danger is low because of the clinical situation in
stole her hairbrush. At this point she involved the which the only threatening words are from this one
legal system, at the demand of her department personality of the patient, who presents as a fright-
chairman, and sent copies of all of the patient's ened child.
letters to the patient, his parents, and her lawyer. A T6. A 24-year-old male diagnosed with schizo-
year later, she began receiving telephone calls and phrenia, after six months of outpatient treatment in
letters of a threatening nature, which she attributes a college mental health clinic, told the psychiatrist
to the patient's response to the legal action. The "time will stop for you." There was no precipitant
letters stated that he would "pull out all of the hairs to this statement, but the psychiatrist reported that
on your body and cut your genitals with glass." the patient had made vague verbal threats previ-
ously, which had not been addressed by the psy-
When the psychiatrist moved, the patient moved to
chiatrist. The patient then stole the doctor's watch
a house within a mile of her residence, and threats
and coat. At the next appointment, the doctor met
have continued intermittcntly over the telephone.
the patient in the waiting room and told the patient
In 1993, he fired bullets into her front window,
that he was being transferred to another therapist,
and neighbors reported that he was seen snooping
but did not confront the threat. The patient never
around her house. The psychiatrist reinvolved the
returned to the clinic and never threatened the
law, who gave the patient probation and a restrain-
clinician again.
ing order for two years. During this time she T7. A 17-year-old female diagnosed with major
attempted to petition for mental health treatment depression and borderline personality had been
but was told that she could not petition for the seen by the psychiatrist for four years. Ten years
same behavior that was in the criminal charge. She after treatment ended, the psychiatrist began re-
continues to receive hang-up calls which she is ceiving death threats by telephone and by letter.
sure are from this patient. This threat has been Police were involved, and the patient agreed to be
ongoing for 22 years. evaluated and then was admitted for inpatient care.
T4. A 28-year-old male with a diagnosis of She was started on medications and at discharge
personality disorder, possible bipolar disorder, and was told that if there was further threatening be-
a history of cocaine abuse threatened to kill his havior that criminal charges would be pressed.
psychiatrist after the psychiatrist missed one inpa- Threats have ceased, although there are occasional
tient therapy session. The patient had been in- curse words on the psychiatrist's answering ma-
volved in intensive daily psychotherapy and had chine, but this happens with a declining frequency.
related personal bisexual fantasies of killing ho- T8. A male in his mid-thirties, who had a
mosexual lovers. He indicated that she reminded diagnosis of schizophrenia and was in outpatient
him of his mother and that he trusted her. The treatment, held his psychiatrist at gunpoint for
threat, which was communicated to the psychia- seven ~ninutcs.The psychiatrist continued to see
trist by the nursing staff, later involved stalking the the patient for a year after this incident, and de-
psychiatrist on hospital grounds. The patient stated scribed retrospectively thinking that the therapeu-
to nursing staff that he would strangle the doctor tic relationship with this patient had become too
and watch her die. The hospital administration intense. No further details are available.
initially refused to transfer the patient, even after TY. The patient was a 30-year-old male with no
the psychiatrist requested the transfer. Finally the formal psychiatric diagnosis who was seeing a
threat resolved after the psychiatrist notified the resident plastic surgeon in the clinic to be evalu-

Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996 375

 Brown, Dubin, Lion, etal.

ated for a rhinoplasty. He had a history of stalking against psychiatrists in outpatient settings.
behavior and threatening with a gun, which was J Clin Psychiatry 49:338-45, 1988
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43-52
and had moved to another state, but she had been
7. Dubin WR, Lion JR, editor: American Psy-
the resident surgeon on his first rhinoplasty. The chiatric Association Task Force Report 33:
patient found her through the unwitting participa- Clinician Safety. Washington, DC: American
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that "you won't be able to operate again." She tion of threats to a therapist. Hosp Community
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transference, and psychological defenses in
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I I. Lion JR: Countertransference reactions to vi-
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Bull Am Acad Psychiatry Law, Vol. 24, No. 3, 1996