Maintaining empathy in a locked psychiatric unit.

Recently, a colleague and fellow psychiatrist who works in an adjacent locked psychiatric unit was the victim of an attack by a patient. He replayed the scenario to me, and 1 of the scariest things about the event was that it seemed to occur without any provocation: the male patient lunged over the nursing station, grabbed him by the collar of his white coat, and proceeded to assault him. Although the incident was broken up by staff fairly quickly, the physician was still struck several times in the face and head, which resulted in a bloody nose and a black eye. The assaulting patient was a young man in his early 30s who was suffering from paranoid schizophrenia, as evidenced by bizarre and persecutory delusions and auditory hallucinations. He was brought into the hospital by his family because they suspected he had stopped his antipsychotic medications and they were concerned about his bizarre behavior. At first, I did not know how to react. I impulsively considered taking karate classes or stopping wearing neckties, viewing all patients as potential assailants. In the days that followed, I became much more timid when seeing patients and walking the hallways. I noticed myself perpetually searching for danger and constantly looking for clenched fists, misplaced hostility, or signs of lability. This preoccupation with potential danger began to affect how I conducted myself. Part of me wondered whether my patients sensed the change or maybe even detected my fear. It was only then that I considered the entirety of the situation—admittedly with some difficulty— and considered the incident from the patient’s point of view. The attack was not the criminal action of a sociopath, but rather an outburst by a patient with mental illness who was feeling afraid and trapped in an environment he was desperate to leave. Determining another’s motives, especially in the case of a psychiatric patient, can be a difficult prospect. Whereas motives and actions can make complete sense in the mind of the patient, they often seem irrational to the observer. When trying to determine a psychiatric patient’s perception or motive, sometimes I feel like a detective, trying to piece together a puzzle with the critical portion missing. In the event of an assault, it can be easy and natural to despise a patient, because a clinician’s behavior would rarely warrant an attack. Although I have never been assaulted by a patient, I have found myself with deep feelings of malice toward several of my patients. Malicious thoughts may not seem altruistic, but they can be invaluable in treating a patient. When I realize and accept these feelings, I am able to view my thoughts as part of the patient’s treatment. If I, as his treating psychiatrist, feel this way, how must every other individual in the patient’s life feel? Once these emotions arise, I find it essential to remind myself that the patient’s conduct and behavior are symptoms of a disease and to refocus my thoughts on being empathic toward the patient. If you are able to envision a world in which your actions cause most people to dislike you, you can begin to imagine the lives of certain patients. I find that this helps me empathize with the patient and, on another level, empathize with people in the patient’s life. Currently, I am a psychiatrist on a psychiatric unit for people with chronic mental illness. At any given time, I may treat between 20 and 25 individuals with a primary psychotic illness. Their lengths of stay vary and can be indefinite, from 2 months to 9 years. The severity of mental disorders of this patient population leaves me frustrated and doubting my skills as a clinician. Finding empathy in these deep moments of frustration can be a steep challenge, but empathy cannot be avoided; otherwise, I risk burnout and ubiquitous unhappiness. When I miss an opportunity to examine a patient’s inner world, I also miss an opportunity to unburden my frustration and doubt. In general, taking a step back and attempting to understand a patient can make confusing and frustrating symptoms seem clearer. If psychiatrists look only at the symptoms of patients, they may be able to treat the patients, but they will not have truly made an effort to understand the patients. A patient needs to be viewed as more than just a set of symptoms or a case file; rather, a psychiatrist should treat a patient as a complete person—taking into account biological, psychological, and social precipitants of the patient—and in so doing truly exemplify the body-mind-spirit tenet of From the Department of