Thursday, March 05, 2009

I'll Show You

Working with violent patients has its challenges. The main one is when they actually do become violent. When they act up, smash things or assault someone there is a quick need to coordinate interventions between security and mental health staff. Of course, safety is the primary goal. Nothing therapeutic can happen until the patient regains control of himself, or someone else gets him under control.

After that, we get him. Violence is actually pretty rare in my facility---a credit to the quality of the correctional staff---but occasionally it does happen.

The only reason I'm writing a blog post about it is because the management of violent patients gets tricky when you're the one they're violent toward. It can be a challenge to continue working with a patient who has threatened you or, god forbid, actually committed violence against you. I've never been decked by a prisoner but I know colleagues who have been. Bless them, they came back to work the next day too.

The question is, what happens next? I don't have the option of firing a patient from my practice and the patient doesn't have the option of switching physicians. For better or worse, we're stuck with each other.

I've put together some general principles about how to manage this situation. Here they are:

1. Safety first

This is obvious, but I'll say it and get it out of the way. Make sure he's cuffed, in leg irons and a waist chain. Custody may forget this in between appointments, so remind them to cuff him the next time he comes down. Have an officer standing outside the office door. If for some wierd reason you don't want him cuffed, have someone sitting in the room with you during the appointment. Bodies count, and it can't hurt to have someone to call for backup if you don't have a security alarm in your office. Confidentiality? Doesn't count here. In cases of imminent dangerousness, there is no confidentiality.

2. Be upfront

Don't pretend that there is a therapeutic rapport when there isn't one. Bring the issue out into the open by saying out loud what the patient is thinking: "You're probably not too happy about seeing me again but we both know you need treatment." It's also OK for you to acknowledge, out loud, that you're going to have a hard time treating someone who threatens you or hurts you.

3. Use timeouts

You and the patient both may need to take timeouts. If the patient starts to get angry, call attention to it and give him a chance to pull himself together. He may not realize how he's coming across. If he continues to escalate, terminate the appointment. In the parlance of the medical progress note, the phrase "appointment terminated for safety reasons" is another way of saying "I let the guy go back to his cell because he was about to swing on me". If you do this, make sure the patient knows you will continue trying to see him and treat him. He may want to run from you, but you can't abandon him. Sometimes that is enough to impress the patient that you're committed to helping and may engage him in treatment.

You need to take a break too if you find yourself getting angry in return. You need to be impartial and calm in order to give the inmate a fair and thorough clinical evaluation.

4. Remember noise is just noise

An angry prisoner will be loud. He might swear. He will complain (a lot). That's all OK. Let it happen, knowing that eventually he will run out of energy. As long as he's not moving toward you or throwing things or physically out of control, it's OK. Don't be intimidated by noise. When he does calm down, quietly ask permission to make a treatment recommendation. There's a chance he might listen once he's had a chance to vent and be listened to.

5. Work on awareness

Like I said before, in all likelihood the inmate is not going to have any awareness of how he's coming across either in volume or in the intimidation factor. When custody starts peeking in the office to make sure everything is alright, you can carefully point this out to the patient and explain that people are concerned because of how he's behaving. That might be enough to trigger insight.

So that's what I do, for what it's worth. Sometimes it helps, sometimes it doesn't. But at least it's worth a try.