Psychiatrist Gives Practical Advice for Avoiding Violence by Patients

“A soft answer turneth away wrath; but a grievous word stirreth up anger,” says the Book of Proverbs, not routinely considered a handbook for psychiatrists working in hectic emergency departments.

Yet potentially dangerous situations can often be defused with advance planning and use of tactics that verbally calm agitated patients before they revert to violence, advised Houston emergency room psychiatrist Avrim Fishkind, M.D., president of the American Association for Emergency Psychiatry. He spoke at a session on emergency-room psychiatry at APA's Institute on Psychiatric Services in New Orleans in October.

For a start, prepare the ground and yourself, said Fishkind, who is medical director of the NeuroPsychiatric Center of Houston at the Harris County Mental Health and Mental Retardation Authority. Remove your ties, earrings, or necklaces, and calmly clear the room of other patients and unneeded staff. Secure the perimeter but keep security personnel outside the room. Resist any temptation to shout at or grab the patient. Maintain a calm demeanor with hands open, arms uncrossed, and turn your body partially sideways to protect vital organs in case of assault.

Keep at least a double arm's length away from the patient, both to respect the patient's personal space and to avoid injury. Maintain normal eye contact (neither staring nor looking away), and offer a visual line of egress by not standing between the patient and the door. Move farther back if the patient requests it.

“If you're worried about who is closest to the door, you shouldn't be in the room,” chimed in fellow panelist Jon Berlin, M.D. “Fake [receiving] a page and get out.”

Address the patient by name and identify yourself and your position as a physician, Fishkind continued. Don't lecture. Speak in short, clear phrases or sentences. To reinforce what you're saying and avoid confusion, repeat the same phrase and ask questions frequently to check patients' understanding. Listen and nod in agreement often.

Try to identify what the patients want and make clear your own wants and needs in this emergency situation. Are they sad, fearful, or angry? Suggest a behavior change that works for both sides: “If you will... then we will...” Offer alternatives, but also lay down the law, too, to establish your limits. Make it clear where you must agree to disagree. Offer quiet time, if the patient needs it, so he or she can contemplate the next step.

Later, debrief the patient both as a matter of respect and as a means of learning how to deal with future crises.

An article by Fishkind, “Calming Agitation With Words, Not Drugs,” can be accessed at<www.currentpsychiatry.com/article_pages.asp?AID=494&UID=63272> after registering on the site. ▪