Saturday, November 13, 2004

Safety first

We're supposed to be prepared for this, but it's scary when it happens: threatening behavior from a patient. My office staff heard my patient shouting and was wondering what to do; we'll have to review our emergency procedures.
The theme of the episode was that the patient was enraged about numerous things...including my reluctance to prescribe certain controlled substances that the patient desired. The patient was standing over me, giving commands...loudly.
Was the patient intoxicated, psychotic, or going through some kind of withdrawal? Was this intimidation? Was I in danger? (My hunch: all of the above.) I let the patient shout, and during a pause, I said, "Obviously you are quite angry." More agitation. Requests for clarification were met with more shouting. After about a minute, I explained quietly that things didn't work that way, and that perhaps the patient would prefer to see another doctor. The patient stopped and said yes. I started writing down referrals, knowing that those docs would hate me forever. (Is it time to call the cops?) The patient then became calm and sat down. (Good! That's good!) Meanwhile, I said, "The goal is for you to be healthy and for us to work together." (Work together? Can we work together? I'm just trying to defuse the situation...I guess it is a goal.) "Being healthy means being off drugs. Working together means I am the doctor and you are the patient, and we talk about what to do."
The patient actually calmed down. Confidentiality makes me hesitant to say more - I've already altered this somewhat - but police support and hospitalization definitely play essential roles in these situations. We train for threatening events, but ultimately we are vulnerable. In psychiatry, we have to think about safety: whether patients are safe around docs, and safe around everyone else. Sometimes there is just no substitute for hospitalization. If, despite treatment, patients are still threatening, we have to decide if we can still safely take care of them.

Substance abuse is a huge challenge. I see so many patients who are deeply, deeply addicted to alcohol and/or other substances. They've suffered horrible consequences. They are miserable. But many don't want to quit. Or they don't like the treatment programs that are supposed to help them quit. Or perhaps there is another diagnosis that interferes with drug treatment (but when they are actively using, it's hard to tell.) Sometimes I ask, "What do you think I will say about your use of substances?" Often, they respond with a long and detailed lecture, with state-of-the-art information about consequences of substance use, and treatment options. They've heard all this before. (Sometimes they say it better than I ever could.) By telling me these things, they've avoided a lecture from me...almost. In my least-judgmental voice, I try to say that obviously they are suffering, and that people feel better when they are sober. I re-affirm the good info that they already know, and explain my dissent from the bad info. I try to be encouraging. If they can't or won't quit, I provide resources to significant others...if they have any. Docs can't force anyone to get treatment, unless they are "imminently dangerous to themselves or others."

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