Tuesday, November 30, 2004

On anger management

When appalling behavior fills the news, I should probably abandon my frivolous tone, and try to comment. I'm thinking about the mayhem at the recent Pacers-Pistons game. Much has been written (and blogged) about causes of the melee. I could quote studies and statistics, but blogging seems best when it's personal. Okay, then...here is what I think about, when I watch video footage of the brawl.

I think of one time when I was clobbered - really hard - in the line of duty, and how I felt, and how I reacted. I don't think I've ever been angrier, and I've never struggled so much to stay in control.

I was moonlighting at a state psychiatric hospital. A nurse called me to see a patient who "didn't look good." I found the patient gasping, obtunded, turning blue before my eyes. What had happened?

Without urgent help, death was imminent. I begged the slow, meager staff to help me. My adrenaline started to surge. I checked the airway, searched for a pulse. Where's the nurse? Bring oxygen, bring the crash cart, where's the chart? Heimlich time. Over here, nurse, help me, please...

Then, out of nowhere, a large male patient chose this exact moment to haul off and punch me. Hard. With force.

Words can't describe my shock, my fury. I still marvel at how much I wanted to hit back. Somehow, I did not. I restrained myself. I screamed at the aides to get this guy away from me and help me, please! The code continued. I didn't notice how badly I was shaking (and bruised) until the blue patient had pinked up and left, via ambulance, for the "real" hospital in town. Had I ever been so outraged? People talk about "seeing red," and breathing fire; about bulls chasing matadors around the ring. Is this what it's like? The sensation felt so new to me...

Now I watch the athlete enter the stands, all boundaries broken, and attack the fans. Some elements seem familiar: the pressure to perform as the clock is running out. The high stakes. People watching. The distractions which must be ignored. The sense of imminent disaster, of things spinning out of control. The surging adrenaline. And then...at precisely that moment...to be hit by a hostile bystander. A boundary violated. An insult, a distraction, a provocation...

No excuses here, no rationalization. Just...revulsion and concern, and a bit of recognition. There is a world of difference between his response to his provocations, and mine. What could have made his response different?

Dr. Centor may be correct. Anger management programs may be as ineffective as most weight-loss programs, drug treatment programs, or any efforts that try to control the strongest human impulses. Aggressive behavior occurs in a context. There are biological factors, as well as environmental factors. Even when these factors are addressed in treatment, there are no guarantees. There may be no alternative to completely removing oneself from known provocations...finding another line of work, if necessary.

I did find another line of work, when I got a letter from the state, apologizing that budget cuts had forced my lay-off. I have not been hit much since then (I've learned something about staying out of the way, and looking behind me). And I haven't been that angry in a very long time.

Afterthought - while I'm at it - is it time to comment on something that is beyond appalling? By now, everyone has heard of the woman who severed her baby's arms. As a blogging psychiatrist, I feel uncomfortable that I have acted as though it hasn't happened, but honestly, I've been searching for something to say. This unspeakable tragedy sends a chill through every person, every psychiatrist, every psychiatric patient and their families. No matter that most psych patients are non-violent. This sends the worst message to the world, and spreads the worst kind of stigma. We all know that one of our patients might do something horrific. It is frighteningly easy for any patient to "look good for the doctor." Just a few phrases can do it: "I really like my meds. You're really helping me, doctor." Patients might really be genuinely okay when you see them in the office...until they aren't.

I guarantee that somewhere, there is a psychiatrist - most likely more than one - who has not slept a single night since this was reported. The suffering of everyone involved...is simply unimaginable, and my heart aches for all of them.
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