I have been working with psychiatric patients for the better part of 30 years. During this time, I have worked in psychiatric emergency rooms, prison wards, substance abuse treatment centers and inpatient psychiatric units. I have been proud of the fact that, despite working in some dangerous areas, I have never been harmed by a patient. I have been threatened, swung at — but never injured. Once a patient decided to use a metal IV pole as a weapon, and I talked him into giving it to me without incident. Over the years, I did not fear physical injury and accepted the fact that violence was a natural part of my job, a symptom of severe mental illness, and as such, something that can be treated.
I am the inpatient director for a locked psychiatric inpatient unit. While leaving a meeting the other day that was on the unit, I was confronted by a patient. He was a large, 30-ish African American man, weighing close to 280 pounds and measuring six-feet tall. He demanded an immediate release. And when I described the process of discharge planning, he became angry, screaming at me, clenching his fists, striking my arm and threatening to “punch my head in.” Attempts to talk to this patient were met with threats, and a manpower code was called. He was given intramuscular medication and was placed in four-point restraints. Aside from minor bruises, both staff and patient escaped unharmed. His anger, however, did not decrease. He continued to verbally threaten me and his treatment team physician. The nursing staff, concerned for my well-being, advised me to avoid the unit. For an hour, I heeded their advice. I left the locked unit and went to the safety of my off-unit office. Sitting safely away from the unit, I became aware of a feeling that was strange to me: fear.
This is not to say that I should have ignored the warnings. The patient was psychotic, delusional and had a history of violence. He had injured staff during this admission, and his behavior was so frightening that his ex-wife took out an order of protection. I would say fear was the normal response, but I could not avoid my responsibilities by hiding. I knew that it would send the wrong message to the staff and the trainees if I allowed the threats to affect my behavior. I returned and was not injured, but the feeling was so great that it followed me after work fear continued, interfering with my enjoying a concert at the Beacon Theater.
There were, I realized, two components to this fear. He was, as I’ve said, larger than me. It was logical, but I did not often avoid similar situations in the past. Perhaps it came down to my perception of the events. I have felt that there has been an increase in violence in the inpatient psychiatric population. Statistics, however, show that these are rare events, accounting for less than three percent of the individual patients admitted to our service.
The staff has told me that the unit is less safe, that there is more violence and that these patients cannot be treated on our unit. I am not sure that if there is more violence, but there has been a change in the way we are expected to approach the patient. Rather than use restrictive interventions, such as intramuscular injections and physical restraints, we are attempting to use interventions that are less restrictive and punitive. Being guided by the principles of trauma-informed care, we attempt to de-escalate using verbal interventions or having a comfortable space for the patient to self-soothe. This has led to staff being unsure how to respond during emergencies. This change over to “patient-centered care” is a relatively new one, and many of the staff working on our unit were trained prior to the advent of these interventions.
Helplessness has become a major emotion on the unit. Afraid to act due to the reviews of these incidents by various regulatory agencies, staff has decided to do nothing allowing the incident to worsen.
Personally, I feel vulnerable. With age, I’ve become less confident in my ability to take a punch. I also believe the blood thinner that I am on works against me. But as I look around, the fear and frustration come from people such as me, older, less fit, etc. Fear is a normal part of this process, but the real problem is teaching others to fear. When I first trained, we were told that the physician is a responsible for patient and that includes when the behavior is problematic. I would often be the first to approach the threatening and angry patient, convincing them to leave a certain area, offering them something to drink and an opportunity to talk. By my avoiding the unit, however, I sent a message to the trainees that we are unable to control the behavior and need to avoid the situation at all cost.
I returned to the unit and made sure that people saw me interacting with staff and patients. I hope that the lesson learned was that we do not avoid treating people who are ill, even if their symptoms lead to behavior that might become dangerous. Senior staff needs to be on the front lines, teaching trainees how to handle these situations despite fear. Allowing the helplessness to take hold will only impair the ability to train the next generation, a younger generation that can take a punch better than I can.
I continue to walk into the unit and round on a daily basis. I have decided to use my fear as a teaching tool. I use to it to validate the feelings that we experience in the face of violence. I have also attempted to teach how symptoms of illness, such as violence, can be treated and that we have an obligation to do so.
Rather than just feeling fearful, we need to be aware of the positive impact our treatment has on these behaviors. For myself, I need to use the wisdom of my years to avoid the punch — or prevent it — rather than being physically able to “take it.”
Constantine Ioannou is a psychiatrist.
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