Violence within psychiatry may be exaggerated in the public eye, yet is a real issue for staff, bystanders, and patients themselves.
By JP Sutherland
Although Christopher’s appearance was absolutely extraordinary, he wasn’t giving any sign (even in retrospect) that he would proceed to kick me in the balls, hard, within the next hour. He was naked, and standing motionless with his arms held out perpendicularly from his sides. Although mute and unmoving for the longest time, if anyone tried to cover him with a blanket then he would shrug it off again, and resume his original posture, nude. His face was tilted upwards, and a beatific smile danced on his lips.
Since the only item on him was a crucifix around his neck, which his stance echoed, and because this was the very early hours of Easter Sunday, there was likely a religious element to his presentation, and I would happily have sat and talked to him about this. However, there were a couple of problems with such a leisurely approach.
Firstly, he was mute, so any discussion about delusional religiosity would be wholly one-sided on my part.
Secondly, since he was standing in the middle of what was allegedly England’s busiest emergency room, this was causing something of a practical problem for traffic, and it was disturbing other patients. When the ER’s charge nurse saw me appear, she let me know all about it.
“Thanks for coming so quickly,” she finished, and then called out to her colleagues, “psychiatry is here, they’ll deal with him from now on.”
Whereupon a couple of ER staff promptly moved on to see other patients, leaving me and Christopher together, and with Mike from security standing like a guardian angel behind me.
I was flattered by being seen as ‘psychiatry’ and representing the whole profession, but the truth was that I was still only halfway through my training. So, the pleasure of my new importance was marred by a little anxiety at my junior doctor status. Over the last few years, I had become relatively comfortable attending the ER for the all too frequent tragedies of psychotic breakdowns and suicide attempts, but this was different. Manic catatonia (if that was indeed going to be Christopher’s diagnosis) was something I had only read about in textbooks. I did have a supervising consultant available on the phone, but I knew from experience that he was going to stay at home and I was going to be the only one on the clinical front line until morning.
I made a few attempts to talk to Christopher, but it was clear that I wasn’t going to get anywhere, and the other staff told me that he hadn’t spoken ever since he arrived. His chart showed that he had been found in the middle of a busy road at midnight, in exactly the same posture, and wearing exactly the same amount of clothing. There was a phone number for his brother listed as next of kin but no answer when I called. The chart was otherwise thin and unhelpful. He was twenty-seven, and his profession was listed as a teacher. He had only been in the ER once before, after he fell off his bike and needed a chest X-ray to rule out rib fractures. And that was it, with no indication of any previous mental health problem.
I had a quick conversation with the ER physician who had made the referral.
“I couldn’t get him to lie down and allow a full physical exam,” she said, “but it doesn’t seem that there’s any medical issue.”
“Any sign of drug use?” I asked, knowing that this is so often a factor in ER psychiatric presentations.
“No track marks on his arms, and the police didn’t mention anything. But I don’t have a drug screen and he’s not co-operating for any blood work. I’m sorry that it’s not the best medical clearance you could hope for, but I think he has to be all yours at least initially. Let us know if you find any reason to worry more about a medical problem and call me back if you need to.”
And with that she was gone. I knew she was probably right, but psychiatrists are always keen to check that there isn’t a medical cause such as a delirium or cocaine use behind a mental health presentation. My concern was that we would have to sedate and restrain Christopher, and then any medical issue would be temporarily hidden under the heavy blanket of haloperidol that we would administer, and so we might miss a major problem until he woke up again in a day or two.
“How’s it going, doc?” asked Mike.
I knew him and his security staff colleagues well enough by now to be able to translate his comment into ‘that’s enough standing around, we need to get him settled and then we have other calls to attend to’. And he was right. I gave the order for sedation, restraint if needed, and transfer to our inpatient unit, and then watched as the injection was drawn up and the staff assembled. Christopher’s eyes watched them too, but otherwise he remained mute and static. At least he did until the three security staff took his arms and led him to a bed. At that point he regained his strength, and then some. His arms and legs flailed, and he temporarily freed himself from their grasp. I had witnessed a few takedowns of uncooperative and belligerent patients, and I could see that this was going badly. They finally got him back on the bed, but since there were only three of them, one leg retained its freedom and was slowing the whole process. So, being the naive young doctor that I was, I took hold of his ankle and helped.
At least that was the plan. In reality, Christopher easily slipped out of my grasp, and his next kick scored a bullseye right between my legs. The next thing I remember is sitting in a chair on the other side of the ER, with Mike looking down at me.
“Are you OK doc?” he asked, and his obvious concern couldn’t completely hide a slight grin. “Best leave the rough stuff to us in future, heh?”
…over the course of their career a psychiatrist can expect to be assaulted a couple of times.
Testicular trauma is a subject that tends to raise a chuckle, and writing about it all these years later I still find myself mirroring the half smile on Mike’s face as he checked in on me. But once the laughter has faded the ugly facts remain. Violence is a serious problem for psychiatric patients, and public safety, and even the healthcare staff involved.
The amount of violence is a real concern in itself, but the perception of violent mental illness compounds the problem manyfold. One of the most persisting and disquieting public images of mental illness is someone who kills while suffering from psychosis, and each country will have its own example of an individual who has performed terrible, and tragic, and occasionally bizarre violent acts on innocent bystanders. Cannibalism and decapitation are extraordinarily rare events, and yet they inevitably draw the media’s coverage, and then sit prominently in the public’s memory, influencing how society reacts to people with mental illness.
The data on psychiatric disorder and violence show a much less dramatic picture. The vast majority of violence in society, around ninety-five percent, is completely unconnected with mental illness, and what increased risk there is varies hugely with diagnosis. Substance abuse carries the highest risk of danger towards others, and this applies whether someone is formally suffering from an addiction and receiving treatment, or is occasionally drunk and has never been involved in mental health care. The risk of violence from a psychotic illness such as Christopher’s is substantially lower than from alcohol or drugs, but may be up to double that of the risk from the general population. On the other hand, mood and anxiety disorders, which are by far the commonest mental illnesses, carry very little increased risk of violence, if any.
People worry about the risk from our patients towards society, and yet they tend not to consider that there is also a significant risk to those suffering from mental illness themselves. The erratic behaviour of someone hearing derogatory hallucinations may lead them to be assaulted, as well as diminishing their ability to perceive risk from others. And the vulnerability of someone suffering from depression or anxiety may make them an easy target for an unscrupulous attacker. The sad truth is that the risk of violence to a person suffering from mental illness is increased at least as much as the risk to others from that person.
And then there is the risk to healthcare staff, which was my particular concern on that Easter Sunday morning long ago. Physicians are victims of assault more than the general population, and it is a genuine occupational hazard of our profession. Emergency room staff fare particularly badly, but mental health workers are equally at risk, being assaulted on average four times more frequently than the average citizen. Putting it another way, over the course of their career a psychiatrist can expect to be assaulted a couple of times. The risk is highest in the earlier years of someone’s professional life, which speaks to inexperience, and fits with my enthusiastic but unskilled attempts to restrain Christopher.
Overall, the public perception of violence amongst the mentally ill is strongly overblown, and I have always tried to reduce people’s irrational fears, as part of generally working to reduce the stigma that impacts my patients. Yet I worry that writing about violent incidents like this may have the unintended consequence of actually increasing the concerns, even as I give statistics to put the facts in context. So, in order to counter that, I need to tell the end of Christopher’s story.
“How’s your courting gear?” He asked with a smile. “No permanent damage I hope?”
I finished Christopher’s admission paperwork, checked that there were no more assessments for me that night, and then limped home to bed. Once admitted to hospital, he was cared for by a different team, whose junior doctor was my colleague and friend Jonathan.
“How’s your courting gear?” He asked with a smile in reply to my questions a few days later about Christopher’s progress. “No permanent damage I hope?”
There wasn’t, and he went on to tell me that Christopher’s illness was a first episode of a bipolar disorder, and that the diagnosis was mania as I had expected. There was indeed a religious theme to his delusions, and Christopher had believed that he was specially chosen as the Lord’s favourite disciple, and was standing naked in the form of a cross waiting to be taken up to heaven. A manic episode of bipolar disorder usually presents with overactivity, but I had been right to think that this was an example of the rare exception where the intensity of delusional joy manifests in stillness rather than action.
Manic episodes usually respond well to medications, and Jonathan said that Christopher was improving as expected. Having checked in on his diagnosis and treatment plan, I returned to my own caseload, and would have thought no more about him. But a couple of weeks later I was walking out of the ward on my way to lunch when I stopped short, seeing Christopher standing across the corridor. He looked well, and fully clothed, and yet I couldn’t help taking a step backwards.
“Dr Sutherland?” He asked. “I’m Christopher. I think we met in the ER.”
“I remember.” I answered, hopefully avoiding too much emphasis on the last word.
“I wanted to apologize for what happened. They told me that I lashed out and I might have hurt you. Are you OK?”.
“Er – yes.” I managed to say, but was wholly uncertain about what to do next. Was he recovered? Was I going to be assaulted again?
Fortunately, Jonathan then wandered along the corridor and seeing us talking he stopped alongside.
“Christopher had said how much he wanted to apologize,” he said, “so I’m glad he found you.”
With Jonathan alongside as a chaperone, we managed a short conversation in which I gathered Christopher was fully recovered and had wholeheartedly taken on board his new diagnosis, and was determined to keep it under control with lithium. He apologized for the assault more times than was strictly necessary, and then left.
“He seems like a really nice guy now that he’s well,” said Jonathan.
“Yeh, probably,” I replied.
“But?”
“It’s just that I’ve never been assaulted before and so I’m not sure how I am supposed to feel towards him. I notice I’ve become more vigilant and less trusting since I was kicked.”
“That’s understandable, but you can’t let it go on too long like that.”
“But how do I change?”
“Here’s what helped me after I got punched last year.” He said, and proceeded to tell me the mantra that I would use from then on, and which can also help anyone come to terms with violence that results from individuals struggling with mental illness.
“You have to separate the individual from the illness. People are not defined by their diagnoses, so you should never think that it was the person who hit you, but the illness.”
All names and other identifying details have been changed to protect patient confidentiality.
This piece was previously published in the journal Hektoen International.
JP Sutherland 