Acad Psychiatry 33:345-346, July-August 2009
doi: 10.1176/appi.ap.33.4.345
© 2009 Academic Psychiatry
After an Attack: How to Deal?
Adam Tripp, Western Psychiatric Institute and Clinic, Psychiatry Pittsburgh
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INTRODUCTION
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To the Editor: Recently, two of the 15 residents in my cohort second postgraduate year (PGY-2) class, including myself, were attacked by patients. My attacked colleague was on the consultation-liaison service and had her hair pulled by a very disturbed 20-year-old female patient with severe borderline personality disorder. The patient was in the hospital for swallowing a plastic pill cup and she had a long history of intentional foreign object ingestion. The patient had become agitated and had scratched a nurse’s arm, and my colleague was assisting in treating her agitation. Following the attack, my colleague spoke with the consultation-liaison director and our residency director. She was upset and took the day off following this incident, but otherwise continued with her daily workload, and she did not report any continued problems or symptoms related to this trauma.
I had been rounding with my attending in the afternoon and had just opened the door from a different patient’s room. A very agitated, large, delusional 54-year-old male patient was waiting, arm cocked back, to punch me. We had begun a forced medication protocol that day, and he was very angry and scared about this development. His thought process had declined; he had clanging, loosening of associations, and derailment. He had significant paranoid and grandiose delusions and was concerned that we were going to hurt him and spy on him constantly while he was on the unit. Earlier in the day, he had threatened to call people who would assassinate me from sniper positions on tall buildings surrounding the hospital. Initially, he was mildly paranoid, but his thought process had gradually declined and his delusions became more potent and prominent after several days of refusing his usual divalproex sodium and risperidone.
My patient connected with his punch, fortunately only a glancing blow. He punched my shoulder and head before I was able to move past him and run down the hallway. I turned around to see him begin to run toward me to continue to attack me, but he was taken down by security and our treatment staff. He was placed in seclusion and given medication as needed for his agitation and psychosis. I continued rounding with my attending psychiatrist. My patient was still in seclusion when I left the unit for the day. My attending psychiatrist congratulated me on joining the  40% of residents who are attacked during their training and had some good advice about prevention of violence with patients, but no one seemed to have good advice about engaging aggressive patients after a personal attack. I had a couple glasses of wine and 800 mg of ibuprofen, which went a long way to helping with the trauma from the day.
I remember thinking as I ran in the next day from home to the hospital, how would I deal with my patient? I was certainly at least a little scared, and I did not know if I would be angry with him or whether my emotions would get in the way of his treatment. He was very ill and very psychotic, so I did not hold him accountable for his actions from an intellectual perspective, but unlike most situations I had encountered in my clinical training, I had no road map or mentoring about what to do emotionally with this situation.
That next day my patient spontaneously attacked an attending psychiatrist who had nothing to do with his care and again was placed in seclusion and medicated for agitation. I was worried about our next treatment session and interview. Fortunately, our encounter was fairly uneventful. We both were wary of each other—he was concerned about more intramuscular medications, and I was worried about another boxing match. Surprisingly, although the attack changed our dynamic, it did not destroy our alliance. We went through our usual interview and both left the session room intact. Over time, he would apologize for attacking me, return to his baseline functioning (which was limited, at best), and be discharged to the Veterans Affairs home in which he had previously been residing.
I did not have nightmares, but I was certainly aware of my unease and fear at our daily interviews for several days after the attack. I was tense until his discharge as well. I was plagued by questions with this case. What if he were more malevolent? What if he had played more on my fears? Would that have made a difference in our dynamic? Would I have been able to continue treating him? What if he had injured me more seriously? How would that change how I saw him and other potentially violent patients? What if he had continued to target me?
Out of curiosity, I did a literature search for coping skills, educational initiatives, or other ideas to address some of my questions. A number of articles addressed the prevalence of assault during training and in one’s career as a psychiatrist (1–4). I found literature addressing training recommendations for improved prevention of violence and assault (1, 2). I also found out how some psychiatrists felt after being assaulted. Unsurprisingly, common responses were "vulnerable," "inadequate," and "feeling alone" in one study of Italian psychiatrists (5). I found no literature addressing how to cope or the unique issues of transference and emotion as both victim and health care professional. I found this astounding, given that the approximate prevalence of physical assault during psychiatric training is 30% to 40% (2). I looked in the psychiatric nursing literature as well but could find nothing addressing the emotional struggles in treating patients after being assaulted.
In summary, in addition to psychotherapy or psychopharmacology when appropriate, I think more thought and creative solutions could be found to help address the unique challenges as a trainee in working with a patient, particularly on inpatient units, after being assaulted by said patient. At the very least, this would bring discussion of this common trauma into the light of day to be examined, and shared, to better treat ourselves and our patients.
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ACKNOWLEDGMENTS
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At the time of submission, the author disclosed no competing interests.
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REFERENCES
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- Black KJ, Compton WM, Wetzel M, et al: Assaults by patients on psychiatric residents at three training sites. Hosp Community Psychiatry 1994; 45:706–710[Abstract/Free Full Text]
- Schwartz TL, Park TL: Assaults by patients on psychiatric residents: a survey and training recommendations. Psychiatr Serv 1999; 50:381–383[Abstract/Free Full Text]
- Fink D, Shoyer B, Dubin WR: Study of assaults against psychiatric residents. Acad Psychiatry 1991; 15:94–99[Abstract]
- Molyneux G, Wright B, Rush G, et al: Psychiatric training-a dangerous pursuit. Psychiatr Bull 2009; 33:189–192[Abstract/Free Full Text]
- Catanesi R, Carabellese F, Candelli C, et al: Violent patients: what Italian psychiatrists feel and how this could change their patient care. Int J Offender Ther Comp Criminol 2009; May 6. [Epub ahead of print]
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