Assaults On Psychiatrists

I remember a supervisor from the past whom I never thought had the right personality to be a psychiatrist.  I mean, he was a little angry and domineering for my taste.  But heck — I gave him a “bye” since he worked in a prison context.

I was never attacked by a prison patient through my tours-of-duty through four (all-male) California state penal institutions.  I had a couple who ended up on their knees, crying, stroking my hands, or even asking permission to kiss me (denied, of course).

They said I was “nice” to them.  I guess I treated them like human beings — something pitifully lacking in the prison system where everything seems oppressive and depersonalizing.

Anyway the unfortunate past supervisor was assaulted by one of his patients in a prison hospital and  the way I was told the story, his orbit was fractured, his eye was put out, and he became blind in that eye.

The orbit, the piece of the skull that protects the eye, is very solid, indeed.  It takes a heck of a lot of force to fracture something that formidable.

This was not a man who dwelt upon the concept of “therapeutic alliance.  Me, I was told early on in training, that was the best thing to do — not only to avoid assault, but to keep patients coming back to continue treatment.

The “therapeutic alliance” is an agreement between psychiatrist (or anyone else who purports to treat anyone and that person) and patient is simply an explicit agreement  to treat the problem the patient wants treated, how it is to be done, and how long until the process will merit re-assessment.

I was a bit scared upon assuming my first prison post, not having really thought of myself as a (potentially chronic) target.

I did what I always do — I reviewed the literature.

The only other clue I found then was a disarmingly simple one — that  I should be honest, and do what I say I am going to do.  This seemed to be particularly true on the inpatient unit.

I remember, for example, reading about a situation where a psychiatrist promised to come back and see an inpatient that same day, did not follow-through, and was assaulted the next day when he did return.

Sounded like a slam-dunk.  I am basically an honest person and would treat any patient nicely, I think.

I am not a fake.  I generally do what I say, and could be extra careful with my (in)patients.

The first time I was assaulted I was not at all clever about psychiatry.  As a matter of fact, I had just changed my specialty from neurosurgery and it was the first psychiatric patient I had ever seen.

The nursing staff (In retrospect I think they should have known better) told me that this particular patient had to be seen quickly.  I was told she would not turn off her faucet, was on the way to flooding her room, and had to be told to stop.

She was an older woman, thin, almost frail, with wiry gray hair.  Really, she looked like somebody’s grandma.

The water had already overflowed the sink and was about two or three inches high on the floor, and was already overflowing into the corridor.

She was happy and smiling.

She was “grossly psychotic,” which means she was living in some kind of alternate reality.  The patient obviously thought that whatever she was doing was “good” or “right” and it clearly was — in her world.

Every psychiatric nurse I have ever known can tell if someone is in that sort of state.  Maybe they just did not know it was my very first day as a trainee.

Maybe they had not even done an initial assessment yet, and simply figured that was what I was going to do.

I simply informed this lady that I was concerned about the flooding and would be personally grateful if she would turn off the water.

She decked me.

She punched me in the jaw.  I fell over backwards, down onto the wet floor.

I quickly found myself on a stretcher, on the way to the emergency room X-ray suite.  The jaw series was negative, I got the rest of the afternoon off, and was back in action the next day.

Since then, I have never — according to my own generally excellent memory — done an initial evaluation of anyone who had a chance of being grossly psychotic without a witness present.

Of course, that might diminish the chance of something going wrong, but would surely not eradicate the danger entirely.

I am glad I did not run from psychiatry, for this is clearly the specialty I need to be in.

Years later, in a facility for veterans, there was a veteran who mumbled something about all psychiatrists needing to die.  I made a run for it, and he was restrained by security in seconds.

He was a PTSD (post traumatic stress disorder) patient from the Vietnam war.  This is what profoundly violent experiences such as combat do to people.  I felt no anger and no blame.

I did not hold this against him, but will admit to feeling relieved when I heard he was safe inside the locked portion of the inpatient psychiatric unit.

Neither incident was something I could have totally prevented.

I have since learned that psychiatric patients are far more likely to present as the psychological equivalent of gaping, open, even painful wounds, than they are as physical threats.

I have seen study after study suggesting that their incidence of violence is not significantly more than the general public.

Still, it is plain that some diagnostic categories, such as those of the two folks I described above, are more likely to get violent than others.

Attacks on psychiatrists are still a concerning issue.

First, no matter how you measure the problem, there seems to be a national shortage of psychiatrists.  It is severe enough that people who want and need appointments often have to wait an incredibly long time to get them.

The recent scandal centering on the Arizona VA system brought this to national attention. Programs to check on people who are in the waiting part of the process are becoming more and more common.

Even animals seem to get “extra protection” if they are members of an endangered species.

Curiously enough, I do not think I have ever heard fear of violence expressed as a reason for NOT wanting to be a psychiatrist.  I do not know whether this is simply because young physicians do not think of it, or whether it is because they do not want to be perceived as “wimps.”

Violence against physicians is on the rise in general.

As a surgical intern, I was a victim of violence but once, but that was enough.

I shall always owe a debt of profoundest gratitude to the policemen of Beauvais (Oise), France, who brought in a (fairly sleepy) inebriated human, who was plainly going to need some stitches.  He suddenly awoke, broke a window, and came at me with a shard of glass.

The police were still present, and protected me gallantly.

My souvenir of the experience is a faint scar a couple of inches long on the inside of my left elbow, sealed under local anesthesia with “tiny fairy stitches” by a senior colleague.

In case there is any doubt of any sort, we live in an age of violence.

Perpetrators are most often intoxicated or have (surprise, surprise) psychiatric histories. Some have suggested that this kind of violence is indicative of problems with the health care system.

Back to psychiatrists.

There are, for sure, certain facilities that are more troubled than others.  I believe it has something to do with the particular mix of patients, for some, such as the intoxicated, incarcerated, or the grossly psychotic, may have more risk of violent outbursts.

Of course, individual security practices are also relevant. The whole situation has to be reviewed for a problem facility, like the prominent psychiatrist (an associate director at the NIMH) who was beaten to death.

The community of psychiatric professionals is sharing an additional warning.

Unknown patients should not be seen in isolated areas.

Even in the quietest of times, there are folks around, at least, in an Emergency Room.

This might be a good warning for folks in some other specialties, too, but there remain other problems.

You just can’t see patients in an emergency setting all the time.

Outpatient clinics seem more comfortable than an office with nobody around.  I guess I would try to avoid using an office space to see patients after hours or when staff is not present – as did the unfortunate Dr. Fenton.

Close physical contact with patients is to be avoided. Reminds me of my supervision while in the military.  There was a superior officer who simply looked inside my office and told me not to sit so close to my patients or I could get raped. I did not think this was enough supervision for a junior clinician at the time but I suppose I may not have had enough experience to appreciate the advice. Specific training might be helpful. I had some, early in residency, something about how to do a gentle, “non-violent” patient “take-down.”

It basically ended with “Yell for help or run like hell,” things which I suppose I would still do at the drop of a hat.

I remember, long ago, my husband telling me that the job in these United States with the most danger of death was President of the United States, proportionately. Of the 43 people who have held the job  —  Grover Cleveland counts twice – a total of eight (about one in five) did not survive until the end of his term, and four of those (about one in ten) were murdered while in office.

I am not sure of the relative danger of being a psychiatrist, when compared to other professions.  I certainly can’t find any relevant studies.

Oh, there are some things categorized as “dangers” other than assault — things like stalking and harassment. I am not changing professions at this juncture, and I have read as much as I can.

So potential patients, please be nice.