I thought I could resist commenting on this issue, but after seeing what the press did with this issue today - somebody needs to set things right. What may be going through a psychiatrist's mind as they think about arming themselves? I don't need to speculate about another psychiatrist. As I recently posted, I have had to make the decision and in talking it over with colleagues many of them had to make similar decisions. It is definitely not a linear process. Here are some of the elements:
1. Contact with aggressive and violent patients who have severe mental illnesses: In another recent post - the most familiar scenario is the person with paranoia or a severe personality disorder and who uses the psychological defense of projection or projective identification. In the popular vernacular a person who tends to blame other people for their problems, even when there is no realistic connection. That can happen to psychiatrists because of the unique a aspects of the relationship and nature of treatment, but it can also happen to other physicians, therapists, and counselors. In many cases the blame is projected onto anyone who works for the organization or clinic and that puts everyone in danger - including the clerical staff.
2. A significant substance use disorder: The usual scenario is the severe psychiatric disorder, aggressive behavior and a substance use problem. Most intoxicants are disinhibiting and they have the potential for activation, increased paranoia, and increased psychosis with impaired judgment. They can also lead to aggressive or suicidal behavior that occurs during blackouts. That not only increases the likelihood of action on a threat but makes any contact with patients in this context very problematic. That includes crisis intervention centers, emergency departments, acute inpatient psychiatric facilities, and detox facilities. It is crucial that all of these settings have adequate staffing and crisis plans to contain both any aggression that occurs and ways to limit access to people with weapons or people who are out of control. In some cases patients with acute intoxication need to be rapidly sedated to prevent self injury or injury to staff.
3. A specific threat against self or family: Any threat needs to be taken seriously and this is also a training point. Every mental health professional needs to learn how to address this issue and the first step is to make sure that everyone in the workplace is aware of the threat. A threat assessment needs to be done and matched with the appropriate plan. Those plans could range from an immediate call to the police, emergency hospitalization, civil commitment, and interventions about how the clinic or hospital will interact with that person in the future.
4. Police involvement: This is not a debate about gun rights. Nobody tells you in medical school that homicidal patients are an occupational hazard. Nobody tells you that if somebody threatens to kill you - you may be on your own. When you hear about some of these scenarios on television and in the movies one of the themes typically is: "Well these are just threats. He/she hasn't actually done anything yet so we can't do anything." That was a very common attitude from law enforcement 20 years ago.
Attitude problems can also exist at the court level. I have testified in hearing about threats where it was suggested that this was an occupational hazard for psychiatrists and therefore less relevant as evidence of criteria for commitment. Nursing staff are also subjected to these illogical attitudes. Assaults on nurses are commonly viewed as an occupational hazard and the administrative response is generally that the responsible patient is never prosecuted. In this era where civil commitment is often watered down to the point that it is completely ineffective, court ordered treatment from a criminal rather than a civil court may be the only available treatment.
A lot of laws have changed in the past two decades and the police should be able to do a lot more at this point. In recent cases of telephone threats, even very indirect telephone threats, the police will often make a visit to the person making those statements and explain new laws about terroristic threats. Any mental health professional should not accept the idea that something beyond a threat needs to happen before law enforcement can get involved. The only action necessary is a threat. What the police actually do is frequently a determining factor in whether a firearm is acquired.
5. A secure treatment environment: There are many aspects to this dimension including access to the physical environment, staffing, and the security arrangements. Are there security cameras? Are they actually monitored by security staff. Is physical access to the environment limited to a few staff? Most inpatient psychiatric units are locked. I have been grateful many times that the locked door was more useful for keeping people out rather than preventing patients from leaving.
6. An awareness that psychiatrists and other staff are killed by aggressive patients: This happens frequently and it has been going on for a long time. It tends not to make the papers anymore. Here is an old New York Times article that was uncharacteristically blunt about the problem. It described a full spectrum of homicidal aggression toward psychiatrists back in 1983. That was the same year that I became an intern and I don't remember ever seeing this article.
7. A functional administration: Lack of an administrative support that prioritizes the treatment of violence and aggression and an associated systems approach to violence prevention is critical. The appearance that a single psychiatrist is in a confrontation with a potentially violent and aggressive perpetrator needs to be avoided at all costs. Staff splitting that encourages patients to act on aggressive wishes toward a staff member need to be avoided at all costs. This may sound like common sense function, but in my 30 years as a psychiatrist, I have never seen a situation like this handled appropriately by administrators. In fact, I have seen just the opposite when administrators dislike a staff person and suddenly there are rapid succession of administrative, staff, and patient problems focused on that person.
It is very likely that the business oriented, "customer friendly" approach to patients that has been promoted by managed care has the potential for making these situations much worse. It is hard to imagine a worse situation than to find out that a potentially aggressive patient who has threatened you is now being taken seriously by various patient representatives, customer service representatives and ombudsman. Many of these patients realize that the state medical board is a gold mine in terms of being able to continue the harassment of the object of their aggression. Multiple complaints against multiple parties can be filed even when it means that egregious threats made by the patient are included in the medical documentation will be sent to the medical board.
8. Dynamic issues: There are a number of critical issues related to individual and group psychodynamics. I have heard the term "therapeutic grandiosity" used to describe a situation where a psychiatrist failed to anticipate a dangerous situation and ended up injured or killed. I think it is far more likely that the psychiatrist involved did not recognize different conscious states of the patient and the fact that one of those conscious states was capable of severe aggression. Many people seem to be confused about legal definitions or reduced capacity here. The law believes that a rational act that is internally consistent with a given psychotic state means that the person is responsible for their actions. Every psychiatrist knows that there are mood disordered and psychotic states that result in decisions that the person would never have made if they did not have a mental illness. One of those decisions is deciding whether or not to become aggressive toward their psychiatrist. Making that determination can depend on very subtle findings. If they are missed and there is an agreement to meet about an issue, especially if it is after hours the clinician may find that they are interacting with an unexpected person. The structure of a clinic schedule and a crisis plan for that clinic can provide a basic background for not making these mistakes.
On an individual level, it is possible to view a patient's aggression as a personal failing on the part of the psychiatrist. Many psychiatrists who have been assaulted are full of doubt about what they missed and whether the care being provided was adequate. It is easy to lose sight of the fact that any physical aggression toward a physician is grossly inappropriate. In the cases I have been personally aware of most of the psychiatrists were spontaneously assaulted and were not even interacting with the aggressive patient at the time. In many cases the assaults occurred by patients who did not even know them.
There are also interpersonal dynamics that are disquieting at times. Other staff speculating on the origins of the assault or threats, acting like the aggressive behavior can be interpreted. This often occurs with little knowledge of the patient and their unique characteristics. In some cases assaultive behavior is explained away on psychological grounds and the person who has been assaulted is unsupported and alienated from the rest of the staff. In my experience, this is a very dangerous position for the the staff to be in. In an incredible twist, the aggressor seems to have more support than the victim even when the victim has sustained obvious injuries. Although it has not been studied, it would not be surprising to find that staff in this position would conclude that they have no support, can expect no help, and need to arm themselves or risk annihilation.
9. Cultural hate of psychiatrists: There is no doubt that the haters of psychiatry have some influence here. It is always easier to perpetrate violence against any minority group that is routinely vilified in the media and seen as a stereotyped monolithic group. The people involved may have difficulty distinguishing symbolic hate and annihilation from the real thing.
All of these factors come in to play in considering whether or not to arm oneself to ward off a potentially homicidal threat. From the psychiatrists I have talked with, next decision is the threshold for self defense. Do you carry a weapon or is the threshold your front door? Are security cameras and alarm systems enough? I knew a psychiatrist who carried a rifle with him when he was riding his lawn mower.
The critical factor comes down to the threat assessment and all of the mitigating factors listed above.
For anyone second guessing a psychiatrist in this position, the critical question becomes: "Where would I allow anyone to kill me?" Is that thought compelling enough to ignore competing ethical considerations, even though there is nothing in medical ethics about a patient trying to kill their physician? Is that thought compelling enough to ignore the law in order to protect yourself and your family? What is your threshold for making those kinds of decisions?
For people interested in stopping this kind of aggression, the points above are all considerations of what can be done to stop it cold - long before there is any gunfire. At that level of analysis, psychiatrists thinking of carrying guns or walking around with them is really a sign as well as an outcome. It is a sign that multiple systems in society and medicine are either inconsistent, have failed or been corrupted. We have these systems in place in some places and they can work. I have seen every one of them work well at some point and prevent aggression and violence.
Fixing that larger problem should benefit everyone including the involved patients.
George Dawson, MD, DFAPA
