Practical Psychotherapy: When Psychotherapy Patients Become Assaultive

My psychiatrist is great! I've been a mess most of my life, and Dr. J is helping me figure it out. He really listens and knows just what I'm trying to say. Except one day last week he seemed distracted; he didn't get what I was talking about. I couldn't stand it. I got so mad I punched him really hard! Later I felt terrible. I tried to apologize, but he kept saying he didn't feel anything! He must have felt something. I hit him really hard. Now I'm confused about what to do. I thought we could talk about everything."

The patient, Mr. S, told this story during an interview with a visiting consultant. Why hadn't Dr. J talked with Mr. S about being punched? Mr. S seemed disturbed by what he had done and bewildered by his psychiatrist's response to this startling event. Dr. J, it would seem, wanted to deny the intensity of the incident and certainly wished to downplay its significance. The patient was left feeling guilty and confused.

Have you ever been hit by a patient? Have you ever been hit or had a missile thrown at you by a patient you were seeing regularly in psychotherapy? If so, what did you do? What did you say? Did you see it coming? Psychiatrists and emergency physicians are the most vulnerable of all physicians to assaults by patients (1). Forty percent of psychiatrists are assaulted at least once during their professional careers, and 50 percent of psychiatric residents are assaulted at some time during their training (2).

Curiously, it is not unusual for psychiatrists who have been attacked by patients in ongoing treatment to make no mention of the assault in subsequent sessions. In a study of assaultive behavior, Dubin and his coauthors (3) reported that 57 percent of the psychiatrists they studied continued to see the patient after having been attacked; of these, 21 percent never discussed the incident in any subsequent session. Moreover, these were not all instances of brief therapies. Thirty-six percent of the assaultive patients had been in therapy for more than a year before assaulting their psychiatrists.

In a study of psychiatrists who had been physically attacked, Madden and associates (4) found that when a patient presented threatening information, the psychiatrists often avoided following up with specific questions that would help in clarifying risk. On reflecting about the sessions preceding an assault, 55 percent of the psychiatrists realized that the patient had reported feelings signaling an increasing potential for violence.

How can we understand this behavior from the group of physicians who are expected to be the most sensitive to the need for open communication in every area of emotional response and behavior?

Psychiatrists, unlike police and other law enforcement officers, do not enter their profession with the expectation that they will be dealing with assaultive, aggressive, or violent behavior. The choice of psychiatry as a profession is motivated by a desire to help and to heal emotionally troubled people. That the patient's emotional instability may be accompanied by physical impulsivity is an unanticipated reality that is thrust upon most psychiatric residents early in their training. Residency brochures do not spell out this aspect of the experience. Yet each year, beginning with the first day on the psychiatric emergency service, the psychiatric resident is looked to as an expert in dealing with violence.

As a first-year psychiatric resident moonlighting one night a week at the Los Angeles County Juvenile Hall, I was asked to resolve all sorts of impossible situations. Around 2:00 a.m. one rainy night I was called to deal with an adolescent girl who had escaped and was now on the roof of the six-story building, throwing roof tiles at the staff assembled below. Suddenly, in the staff's eyes, my professional image was transformed from that of "the shrink," whom perhaps they did not think of as a real doctor, to "Wonder Woman," who could influence an impossibly violent juvenile. "Talk her down," they said. I hesitated, thinking that somehow I ought to be able to do as they asked. Then reality prevailed. "You get her off the roof," I said, "and then I'll talk her down."

Such demands and public expectations occurring early in a psychiatric resident's career can produce a sense of shame in the face of fear and vulnerability. Subsequent counterphobic reactions to these feelings can place psychiatrists in harm's way. In the situation at Juvenile Hall, my humiliation was somewhat diminished by the staff's appreciation that I had no special powers of voice amplification, and it would have been impossible for the agitated adolescent to hear what I was saying, let alone to respond appropriately, while she was six stories above us busily throwing roof tiles.

Today many residency programs do provide education about the management of violence. However, often not enough time is spent on how to approach a patient psychologically, how to assess the patient's level of arousal, and how to apply deescalation techniques. Similarly, how to anticipate what may occur in a psychotherapy session, including the effects of transference and countertransference, may be given short shrift.

What signs or characteristics should alert the psychiatrist to the possibility of a future assault by a patient being seen in psychotherapy? Any patient who has a history of hitting someone may someday create the need for their psychiatrist to manage the development of violence in a psychotherapy session. This includes patients who have been in street fights or brawls or have on occasion "snapped" and hit their girlfriend, spouse, the wall, or a passerby.

Psychiatrists who are convinced that they have a good therapeutic relationship with a patient may be less likely to realize that someday they too could be the target of such assaultive behavior. In theory psychiatrists know this, but in their day-to-day work, if they feel comfortable that they have a good working alliance with the patient, even the most sensitive psychiatrists can lose sight of the affective or impulsive instability that can be a product of the patient's illness. There is always the possibility that the strength of the affects and the intensity of precipitating events may break through the barriers created by a good therapeutic relationship and cause an unforeseen attack.

That is very possibly what happened to Dr. J. If therapeutic work is to proceed, these issues must be explicitly addressed after the storm has passed. They must never be put aside as though the event had not occurred.

To complicate matters, some assaultive patients have no history of such behavior. A patient whom Dr. A had seen for a year in psychodynamic psychotherapy had described a repressive childhood in which there had been no opportunity for the expression of negative feelings or impulses. Dr. A encouraged the patient to give vent to his feelings and reactions as part of the therapeutic experience. This encouragement led the patient to launch increasingly virulent verbal attacks on the psychiatrist. The insults were all related to real, although very minor, inconsistencies on Dr. A's part. Not returning a phone call immediately, arriving one or two minutes late to a session, offering a response that was not perfectly attuned to the patient's needs all resulted in angry verbal outpourings.

Dr. A. absorbed this punishment and interpreted it, but in his desire to be an empathic person in the patient's life, different from those who had dominated the patient's upbringing, he did not recognize the strength of the patient's escalating aggressive impulses. He also lost sight of the fact that the patient had no experience with feeling and verbalizing his intensities while maintaining self-control. Eventually the dam burst. One day, enraged by Dr. A's misunderstanding of a statement, the patient hurled a heavy vase at him, barely missing him before it smashed against the wall.

In retrospect, Dr. A realized that the event made psychological sense. Had he seen it coming, he could have helped the patient gain control and thereby avoid the humiliating and potentially dangerous act of hurling a heavy object at his caregiver. Whatever therapeutic orientation is offered by one's training, the dictum that our task is to help patients put their violent feelings into words, not actions, is a universal one.

Given the failure of anticipation, the next step is to address the violent event. Investigating what was going on that led to the outburst, looking for ways to anticipate future problems, and putting in place a strategy to deal with mounting rage become valuable tools to help patients not only sustain the treatment situation but also deal with their everyday lives. For some patients it means telling them explicitly, "You can talk about what you are feeling, but in this office you cannot act on those feelings." If a patient becomes dangerously explosive as he describes his feelings, he must be asked whether he can contain himself in the room. If he needs to leave or have a time-out, arrange for him to return later. "Returning later" is vital so that he knows that his rage is not going to lead to abandonment.

Some important points should be kept in mind.

• Learn to recognize the signs and symptoms of escalating agitation that may lead to an assault.

• Never think "it couldn't happen to me" or "my patient would never hit me—he or she might hurt others, but not me."

• After the episode has been dealt with and the patient is under control, review the episode with the patient in a manner that is calm, inquiring, and designed to be helpful.

I once asked a colleague what he thought about Dubin and associates' (3) finding that a fifth of the psychiatrists in their study who had been assaulted elected not to discuss the incident in later sessions. He replied, "Sure, I know why they don't bring it up; they're afraid the patient will hit them again." Ask yourself, "Is that what I think or feel?" If so, or if your fear is disruptive to your fulfilling a therapeutic role, consult with a colleague or supervisor and explore the situation. Just as patients do not commit suicide just because we ask them if they are suicidal, patients do not become assaultive just because we ask them if they are feeling that way and whether they believe they can contain themselves.

If you have been assaulted, you must talk with a colleague or supervisor to develop an understanding of what happened, of how you feel, and of the possible effects the event might have on you and your career aspirations as well as to figure out what to do next.

Psychiatrists need to recognize and understand their feelings about violence: the fears, hatred, dislike, excitement, and confusion. Thoughts, fantasies, images, and occasional acts of violence are common to our patients' emotional struggles and thus become an integral part of our professional lives.