Heroism: in the age of COVID, it’s a word we often use to describe healthcare professionals. It refers to their willingness to go to great lengths—sometimes at risk to themselves and their families—to care for the patients they serve.
But viruses and pandemics aside, healthcare providers face one danger that often goes unacknowledged: mistreatment by the very patients they have pledged to help.
At Connecticut Mental Health Center (CMHC), the subject of patient abuse of staff took center stage this fall as over 100 staff members (and counting) participated in “ERASE-ing Mistreatment by Patients,” a 90-minute interactive training designed to help healthcare professionals develop strategies to respond to harmful patient behavior. ERASE focuses on verbal abuse; while physical abuse is also a problem, verbal mistreatment, such as racist, sexist, or otherwise prejudicial language, is far more common—and commonly ignored.
Inside a meeting room filled to capacity, the energy in one ERASE training at CMHC was palpable. People from all levels and backgrounds had gathered to discuss a problem they have witnessed and experienced. Until today, it wasn’t a subject they had been encouraged to talk about. Now they were talking about it—together.
Overcoming Barriers
“What are the barriers to addressing mistreatment and harassment by patients in healthcare?”
Before getting to the specifics of ERASE, lead trainer Kirsten M. Wilkins, MD, a professor in the Yale Department of Psychiatry, asked that opening question. It sparked a lively conversation about why avoidance has been the cultural norm for so long.
Staff reflected on a range of barriers: the lack of clear policies, absence of consequences for verbal acts, excuses given to patients because of their mental illnesses, and the slipperiness of language, which is always open to interpretation. Some providers said they feared damaging the therapeutic alliance, a cornerstone of effective mental health care. Others noted that when they hear verbal mistreatment, they sometimes wonder when is the right time to say something—and they puzzle over what, exactly, to say.
“You’re not alone,” Wilkins assured them. These are the same barriers she and her colleagues hear everywhere they conduct the ERASE training. Patient mistreatment of staff is increasingly common in healthcare settings across the country, she said, and women and people of color are significantly more likely to be the targets. Organizational policies that deal with staff-to-staff violations don’t easily map onto the patient-provider healthcare relationship.
Roots of ERASE
The ERASE model, which stands for “Expect, Recognize, Address, Seek Support, Establish/Encourage (a positive culture),” was developed a few years ago by Wilkins and fellow faculty members Kali Cyrus, MD and Matthew Goldenberg, MD. Based on their own experiences as providers, teachers, and trainees, they recognized the need for an intervention that would help build safe, positive, and supportive healthcare environments where clinical care and learning take place without fear. Mistreatment of staff by patients is detrimental to patient care; yet, Wilkins said, there is a long history of healthcare organizations discouraging staff members from talking about their mistreatment. That has begun to change.
“Over the past few years,” Dr. Wilkins told the group, “people started saying, ‘I don’t have to take it, but I don’t know how to intervene.’”
A Community Mental Health Center Embraces ERASE
Jeanne Steiner, DO, Connecticut Mental Health Center’s medical director who hosted the ERASE training for staff and faculty across the organization, credited psychiatry residents, fellows, and other trainees—the next generation of providers—with bringing the issue to the fore.
“They were the first ones to talk about it in a different way,” she reflected. “I think before, we would try to laugh it off, or say, ‘That says something about the patient’s level of illness.’ But the trainees talked about it in terms of racism, the experiences they were having, and how harmed they were.”
“Over the past two years,” she added, “it’s been a big topic of conversation at CMHC.”
So when Wilkins invited fellowship leaders across the Department of Psychiatry to participate in ERASE, Dr. Steiner, a professor and director of the Yale Fellowship in Public Psychiatry, decided to go. In addition to wanting to experience the training herself, she wondered if its model might be adaptable to CMHC, with its diverse staff and deep experience serving adults with serious mental illness, many of whom have histories of trauma, substance use, and incarceration. Over the weeks that followed the fellowship directors' training, Steiner convened a planning team to host ERASE at CMHC.
The response was overwhelming: 105 staff members from across the organization signed up to attend one of the first three sessions, including mental health assistants, nurses, social workers, administrators, and doctors. Dr. Steiner and her planning team achieved their goal of mixing together staff from outpatient and inpatient units. “The settings are very different,” she explained. “The patients have different levels of acuity. We felt the staff really needed to hear from each other and learn what the complexities are.”
“We are the safety net,” Steiner noted, referring to CMHC’s important role in the community as the mental health provider serving people without income or insurance. “But we have to be a safe place for everybody.”
Dr. Wilkins led CMHC’s ERASE trainings along with Gabriela Garcia Vassallo, MD and Carrie Lukens, PhD. All three are clinically active at the Veterans Administration Hospital in West Haven and faculty members in the Department of Psychiatry. As fellow mental health practitioners, they understand the CMHC context well. While people with mental health and substance use disorders aren’t any more likely than the general population to participate in abusive behaviors, it can be especially challenging to address behavioral issues with such patients because behavior is often a manifestation of illness.
Moreover, while some types of verbal abuse, such as racist slurs and sexually derogatory language, are obvious, others may be less clear—especially for bystanders who don’t belong to the identity group that is being targeted.
Exploring Case Examples
The heart of the ERASE training involved in-depth conversations about three hypothetical case examples presented by Drs. Wilkins, Garcia, and Lukens. The scenarios typified common forms of verbal mistreatment, but also involved some nuance. Participants’ responses, explored first in small breakout groups, were not uniform. When asked to report to the full group, people shared a variety of ideas, opinions, and beliefs.
Wilkins emphasized that it is important to intervene whenever mistreatment occurs. But how to intervene is more art than science. She continued, “Ask yourself: what is the purpose of the intervention? What is my goal? What is my relationship with the person? What is the context?”
Bystanders are often key to the response. “Bystanders can become upstanders and intervene when we see our colleagues targeted,” Wilkins explained. She noted that interventions aren’t just for the individual patient, but also for anyone who witnessed the abuse. She encouraged staff to respond even in situations when the patient isn’t able to listen.
“Sometimes an intervention sends a message to everyone else around you,” Wilkins explained. “It’s important that they hear this is not okay—that we don’t tolerate that kind of language. It supports those in the milieu and sends a message about the values of the institution."
Changing Culture
CMHC has conducted three trainings to date, and more are on the calendar. A follow-up survey for participants confirmed that many staff have been mistreated by patients—especially based on age (61%), race/ethnicity (41%), and gender (39%)—and that there is a need for more training. Over 85% of respondents said ERASE increased their awareness of mistreatment in a healthcare setting and helped them develop a framework for addressing it. Following the workshop, everyone’s confidence had increased.
And this is just the beginning. Inside CMHC, staff are already working on follow-up projects, such as developing new communication tools based on what they learned from ERASE.
The point of ERASE isn’t to eradicate the problem. That would be an unrealistic expectation. Wilkins and colleagues taught the group to “expect” incidents to happen—the first “E” in ERASE. However, for progress to occur, the final “E,” encourage the development of a positive culture, is crucial. ERASE laid a new foundation for changing the workplace culture by empowering people to respond and sharing principles for how to do so.
Expressing her hope for the CMHC staff going forward, Steiner said that while verbal mistreatment may not go away, “We can work toward reducing the frequency of events and reducing the impact and the feelings of harm that people experience. We can educate people and really change our culture.”
The ERASE model, Steiner reflected, is wholly non-judgmental, and that’s part of its power. The training helped staff members get to know each other better and fostered their capacity to have constructive conversations even when they do not agree.
“It showed that we can find ways to work on this problem that are respectful of our differences,” she said. "We can think through situations together and build a sense of community.”
Steiner isn’t the only person feeling optimistic these days, thanks to ERASE. As one longtime CMHC staff member said at the training, “This is an excellent thing, and I’m really happy to be here.”