Dr. Rob and Violence - June 17, 2008

Dr. Rob,

I work in a high security psychiatric hospital and was told that while highly unlikely the patients could become aggressive at times. I'm new to the field (I have a Bachelor's Degree in Psychology) and I wouldn't say I'm afraid but at least concerned. Have you ever been involved in any episodes of violence? How did you handle it?

My massive 165 pound girth prevents most people from attempting to mess with me. And violence in mental health settings is not a common occurrence, at least not to the sensationalized degree you might see on television, so keep that in mind. But that doesn't mean it isn't a good idea to take basic precautions. Some of the most common are to always sit closer to the door than a patient, never put your hands on a patient without prior warning and do not wear items that can be used as weapons against you, such as hoop earrings or necklaces that can be pulled on. Using common sense and respecting your surroundings can greatly lower your risk of trouble.

I have limited experience in the setting that you describe so I can't speak in detail about that type of work. That being said I have had a few tense moments with my clients over the years. In graduate school I worked in a residential treatment facility for teenagers with behavioral problems. These adolescents struggled with substance abuse, school truancy, were victims/perpetrators of physical abuse, had poor intellectual abilities and had little to no parental involvement in their lives. This was in addition to psychological problems such as depression and anxiety. These kids had been removed from their homes or the streets and placed in the facility for both treatment and schooling.

My job was to perform psychological testing on the residents to help develop psychological treatment plans. In addition to completing standard I.Q. tests and screening measures for ADHD, part of the testing battery required each teen to complete a very lengthy true/false test. The test would ask questions about psychological symptoms, personal interests and coping styles to help understand a client's personality and any mental difficulties.

Because the test was hundreds of questions in length the teenagers understandably got frustrated filling in oval after oval on one of those stupid Scantron sheets. And because many of the students had lower I.Q.'s they had trouble understanding many of the items. One student, I'll call him Sam, was just under 18 when he completed the testing. He was tall, at least 6'3'', and well over 240 pounds. If he and I comprised a Mental Health Football Team he was clearly the linebacker and I was the kicker. Possibly the waterboy.

To Sam's credit he worked very hard on everything he was asked. Normally the entire testing process took about three hours, conducted over three visits. Now on our fourth visit and sixth hour of work together he was getting frustrated. The testing room was hot, small and overcrowded with a big person (him) and a little person (me). At one point he came to a question that I to this day have trouble comprehending. It was one of those triple or quadruple negative statements that canceled out each other making it a positive. Or maybe still negative. I'm not sure. To paraphrase:

True or False: I do not enjoy not thinking about past mistakes or failures that will sometimes or often not bother me.

Sam read the question silently. Then aloud. Then silently again while mouthing the words. The pencil, which looked more like a toothpick in his hand, began to suffocate from the gradual squeezing he began to apply to it.

"True or false. I do not..." and he closed his eyes. Squeezed the pencil. He softly hit the desk with a fist. The pounded with both hands.

"I don't...get it!"

Having a client get angry was never a big deal for me as I viewed it as simply another human emotion that will ebb and flow with time. However when the pencil cracked and a second set of fists slammed down on the table a series of questions started to run through my mind:

This isn't therapy but should I let him work through the emotions? Should I tell him to just take a break from the test for awhile? If I do will that skew the results? I'm sitting closer to the door than he is; should I just run away from this place forever and go to dental school? Maybe I should I explain the question to him; hell do I even know what the question is asking?

"I DON'T UNDERSTAND!" he yelled and his now red eyes stared at me.

Using my street language that always went over well with the young ones I decided to try to relax him. "Hey man, it's all good. It's cool. This isn't such a big deal, let's just chill for a bit, kick it, and we'll come back to it."

Sam wasn't about to be consoled. He stood up, furious. In the corner of the small room was a statue of the Virgin Mary (the treatment center was Catholic-based facility), about five feet high. He walked over to it, stared it down and picked it up over his head. The room we were in couldn't have been more than eight by eight so if he slammed it down the consequences were limited:

1) Have the statue break apart all over the floor with the shrapnel flying all over the room, puncturing our vital organs, killing us both.
2) Smash me over the head with it, killing just me.

Watching him hold the statue up high I really started to get anxious. Then it crossed my mind that I should take a more authoritative approach. I stood up, tried to look as tall as my near six foot stature would allow, and pointed my finger at him.

"Sam! You put that down right now!"

I don't know if he saw my finger shaking from fear but he paused, stared at me for a moment and actually lowered the statue to the ground. I couldn't believe it worked. Sam then ran out the door, slamming it behind him.

I took a few moments to collect myself and thought about the people who would have missed me if I had died. Mom, dad...mom some more. I then went down the hall toward Sam's classroom only to find Sam leaning against the wall in the hallway.

"Sam? You okay?"

"I don't understand. I hate that I don't understand," he said, no longer yelling.

"I know, man. You have trouble with these things. But in all fairness to you it's a really confusing question. It's complicated."

"Will you help me?"

"Well I can't tell you exactly what the question means. In fact I'm not even sure myself what it's asking. But how about we do this: let's skip that question and go on to the rest of the test. You're almost done. When you're finished we can go back to that one and try again. If it still doesn't make sense to you then we'll just skip it."

"I can skip questions?"

"I think you can leave five blank so you're okay. But I'd like you to try again."

"Okay."

"And Sam? When push came to shove that was a good job in controlling your anger. Thank you for not killing me with that statue."

Sam smiled. "You're welcome man."

Sam ultimately decided to leave the question blank but completed everything else on the test. That was more than many of the other kids did so I was happy for him. And when all of his test results came back they showed he was actually smarter than originally estimated with stronger coping skills. Like knowing when to not break a statue. My guess is that Sam probably doesn't have the easiest life but he may have made something of himself with the right guidance.

I'm not entirely sure what the moral of this story is but it probably has something to do with not keeping religious artifacts in your testing room. And try to keep your finger from shaking when you confront a large teenager. And of course know your double negatives. Good grammar is obviously a key to mental health.

Posted by Rob Dobrenski at 1:37 PM

Print Friendly · Digg it · del.icio.us · StumbleUpon · Netscape

Trackback Pings

TrackBack URL for this entry:
http://www.festeringass.com/mt/mt-tb.fcgi/2468

Comment Policy:

Anonymous comments are allowed. All anonymous comments and comments from those not registered with TypeKey are moderated. They WILL NOT appear until they are read and approved by a moderator.

It is strongly encouraged that you sign up and login with a TypeKey account. Once you do that, your comments will be immediately posted.

Comments

I worked as a Licensed Nurse Aide in a Nursing Home. It was not uncommon for some of the residents to become aggressive to the Nurses. (For instance: one of the residents with dementia would try to hit any of the nurses who tried to bathe her.) While her age hardly made her a danger, I do have some simple advice about confronting hostile patients. Plan ahead. Between your colleagues and the reams of paperwork you will have on all the patients you will deal with you will be able to know who to watch out for and what sets them off. There is no need to place yourself in danger.

Posted by: Noggy at June 17, 2008 02:49 PM

If there's any chance at all of patient violence:

Never put anything between you and the exit. Don't sit so that the patient is between you and the door. Don't put the large table/couch/shelf between you and the door.

Posted by: VK at June 17, 2008 03:13 PM

True or False: I do not enjoy not thinking about past mistakes or failures that will sometimes or often not bother me.

Simplified

True or False: Thinking about my past mistakes or failures are things I benefit from even though they will sometimes or frequently bother me.

Posted by: Roxxy at June 17, 2008 03:44 PM

This made me sad more than anything. I can understand Sam's frustration. I scanned the question and basically said "what the fuck?" I'm wondering though....had he said before that he hated that he couldn't understand something? Could that possibly have been some kind of breakthrough? Ugh...I feel the need to save the world now. Fuck Rob. This one turned me into mush.

Posted by: Amber at June 17, 2008 04:57 PM

I'm a pretty intelligent guy. I was a child prodigy for a while and did pretty well in university. I scored in the top national percentile for some standarized aptitude testing I did a while ago. I've read that question like 5 times. I've tried rephrasing it, eliminating the double negatives, and considering the motivations of the writer. I can only assume that it's meant to be a trick question and the only sensible way to pick an answer is to flip a coin.

On a side note, when I was 20, I had a roommate who was in his final year of learning to be a teacher, and he was going out to do a few months of practical examination or student teaching in a school. One of his classmates - a pretty, 110 lb blond girl didn't get a placement, as there weren't enough schools to go around for students. There was a note that went to all the students that said while the university didn't place people at juvenile detention centers as part of the allocations process - volunteers could take a spot at the boys facility, instead of waiting until next semester for a place. We actually had to talk the very pretty, 110 lb blond girl, out of volunteering to be placed at a boys juvenile detention center.

Eventually we had to introduce her to a friend who had worked at a similar facility previously, and show her the scar on his hand from when a student stabbed him with a pencil.

Posted by: Scootah at June 17, 2008 06:22 PM

I work in a community mental health facility, so we see our fair share of agitated patients on a weekly basis. Between the staff and patients, there have been no incidents. People ask me all the time, aren't you scared? No, no I'm not in the slightest, as these folks actually appreciate on some level what you are doing for them (even the borderlines) and do not see us as a target. Never hesitate to call the police either, I didn't go to school to learn how to break a full nelson. I think that is something that you really have to learn by doing though, to learn what you are comfortable with and what to do automatically.

Relating to Amber's comment: I worked in a juvenile residential halfway house and that was hands down the most scared I have ever been, and I have been on forensic units with murderers. Teenage Blooming Borderlines in an enclosed environment all trying to outdo one another, simply wonderful. One evening at the house, a kid attempted to stab one of the staff members in the temple with a sharpened end of a toothbrush, wrestled over chairs and tables. I resigned the next day.

Posted by: Mark at June 17, 2008 09:44 PM

If the staff don't train you, you are screwed. Did time locking up longterm special populations into solitary at a max seq yard. They spit at you, throw there piss and shit cocktails at you if they didn't get a letter. They go cage crazy all the time. Just make sure that no matter what, they take their meds. That is very important! If you are working with juveniles get shinguards, they like to kike in the legs,bicthes. If your the Doc going in, have a handler back you up, till you get the feel of it. Just know where the door, the sniper,the alarm pull all are (hopefully behind you). No sweat.

Posted by: iraqmaq at June 18, 2008 12:36 AM

sup Rob,

"Using my street language that always went over well with the young ones I decided to try to relax him"

great story, that paragraph made me laugh. You are so street.

I had images of you just having read Malcom X and then blurting out random 1960's Harlem jive speak.

"My Man! Chill Dadio! Sheeeet, man, that honkey mus' be messin' my old lady got to be runnin' col' upsihd down his head!"

Posted by: jackmo at June 18, 2008 03:34 AM

Another handy street phrase is:

"Legga down 'n smackem yackem! Cold got to be."

Not sure what it means, but it must be some voodoo incantation because usually people are stunned into silence at least long enough for me to run away. When running away under those circumstances, usually my feet make the 'ricochet' sound, like in The Flintstones.

Posted by: Disciple of "Bob" at June 18, 2008 08:17 PM

"Normally the entire testing process took about three hours, conducted over three visits. Now on our fourth visit and sixth hour of work together he was getting frustrated."

Hey, Doc R, Sam got a little worked up, did he? A hot, cramped room and a lengthy, stupid-a$$ test can do that to a person, I guess. If if were me, I'd be wanting to throw a statue, too. Or a fit. In the name of helping others, torments, big and small, can occur via the System. It also bears mentioning that violence can go both ways, too. Practioners, health professionals and guards can be violent toward their charges. Not that you were. You showed admirable restraint. And, some mighty fine street cred, too! (Like I would even know...:)

Posted by: Borderline Betty at June 19, 2008 10:18 AM