Patient assault – An insider’s view

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I saw the patient standing near the door of the unit, watching me and shifting from foot to foot. This in itself wasn’t unusual. At our forensic hospital some of the most seriously ill patients have behaviors that are stranger than this if not overtly bizarre. As I was leaving the unit, he approached me, which also wasn’t unusual. Although I wasn’t the ward psychiatrist, a patient might approach a stranger to find out what that person is doing on the unit or just to say hello if the patient knows you from a previous court-ordered evaluation.

I wasn’t expecting him to hit me in the face, twice. My glasses flew off; my head flew to the side, but I was still able to immediately shout for help to the nurses within the station. As soon as the attack began, it stopped. He calmly dropped his hands and walked quietly away. The nurses quickly moved between the two of us, a calming human shield. My initial reaction was anger. I didn’t know this patient, wasn’t his doctor, and had had no previous negative interactions with him. It just wasn’t fair!

"We’ve all been there," my friends and colleagues said later. And this was true; off the top of my head, I counted at least five psychiatrists I knew over the years who had been assaulted by patients. That’s probably an underestimate, given how long it’s been since my residency and my time working in an emergency department.

Still, I consider myself fortunate. I was bruised but not significantly injured, and it could have been worse: a dislocated jaw, a broken nose, a skull fracture, or even homicide. A casual Google search limited to the last 2 months turned up news stories about injuries like this inflicted on staff in state psychiatric facilities in at least five other states, and most of these stories commented on the increasing frequency of patient-on-staff assaults. Some states have even proposed legislation to make patient-on-staff assaults a felony offense regardless of the level of injury.

After the incident I spent about an hour filling out the OSHA-mandated paperwork. One form included a checkbox to answer the question, "Do you want to file criminal charges?" Without a second thought, I checked off "no." In retrospect it was a curious reaction, given my initial anger over the incident. I think instinctively I knew several things: I knew that the patient was likely a person with a treatment-resistant illness, a long-term institutional patient, who was repetitively assaultive in spite of all clinical interventions; I knew that a state’s attorney would likely be unwilling or uninterested in prosecuting someone like that; and finally I knew a prosecution would take many weeks and take up more time than I was willing to invest. My gut instinct was that prosecution would be not only unjust, but also a colossal waste of time.

This is not to say that prosecution of assaultive patients is unjust or useless in all cases; I’m aware of at least one case where the stern admonition of a judge, combined with a substantial suspended sentence, led to an almost miraculous change in behavior.

Apart from forcing me to directly confront the decision about prosecution, the incident gave me the opportunity to question my choice of specialty and working environment. I have to say that safety has never been a primary concern, given that every place I’ve ever worked has made safety a priority. My hospital was even recently given an award for a reduction in assaults. And I’ve always been careful to take personal responsibility for my safety and to speak up if I have a concern about an unsafe patient or situation. This event won’t change the enjoyment I have in my specialty, or my dedication to the work.

I do have a new appreciation for the potential psychological fallout, which I think may be somewhat different for forensic psychiatrists compared with general practitioners. Forensic psychiatrists take pride in being willing and able to work with dangerous patients. Given this, there may be more pressure to respond with bravado and trivialize injury, or deny emotional distress over the incident. There may be embarrassment for failing to predict or assess a potentially dangerous clinical situation. For consultant evaluators, there may be a risk of displaced anger toward evaluees and potential bias toward assaultive criminal defendants. But as with general psychiatrists, awareness is the first step toward minimizing those risks.

Finally, some colleagues view the goals of security and therapy as incompatible, particularly in correctional settings. This incident highlights the fact that the best treatment can be given when both the patient and the clinician feel safe.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.