Shrink Rap Today

Three psychiatrists explain their work

Can I Hit Back?

You can assess violence, but what if you are attacked?

One of the challenges of being a psychiatrist---and a forensic psychiatrist in particular---is that we are more likely to deal with patients who can become violent. Psychiatry residents are usually trained in violence risk assessment and management. In my own residency I recall having to go through training in "take down" and restraint procedures. As a group we practiced applying pressure point joint locks on each other in order to make a patient break a grip on us, and to do two person restraints to hold someone immobile until security could arrive. None of this involved any "Crouching Tiger, Hidden Dragon"-type kung fu moves, and there was no kicking or hitting or loud kiai karate yells. There was a lot of talk about the importance of using the least amount of necessary force. Frankly, I'm not sure how much of that I would have remembered if I had ever been in a position to have to use it. The few times when I was actually assaulted by patients the incidents happened so fast there really wasn't anything I could have done. (OK, so the little manic lady who hit me with a stuffed dog really couldn't count as an assault, and she was already restrained in a geri-chair to begin with.)

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A question was posed to me recently that raised a new issue: if a patient attacks a doctor, is a doctor allowed to defend himself?

In situations like this it's always best to think clinically before thinking legally. Safety first. Do what you must do to protect yourself. Learn the security procedures for your hospital or clinic or school or correctional facility, and know them so well you don't have to even think to act on them. If no one orients you to security procedures on your new job, make a point of asking. (Free society employers are particularly bad about this, particularly in an outpatient setting.) Even when you follow the "right" procedures though, it takes some time to get help. By "time", I mean several seconds to minutes, and in that short time a lot of damage can happen. Yes, doctors can and should defend themselves from attack.

What are the potential legal consequences? (Disclaimer: I'm not a lawyer, anything I say can and might be wrong from a legal standpoint, when in doubt call your hospital counsel or malpractice risk management office.)

The consequences could be civil or criminal. An assault or battery charge could be filed by a patient, or a general tort (injury) civil suit could be filed against a physician. A malpractice claim could be made (I doubt anyone could claim that a physician assault against a patient would be a standard part of psychiatric treatment!) however in states that allow contributory negligence (a limitation on damages when an injury is caused in part by patient behavior) the physician's liability would be limited. Finally, the patient could file a board complaint against the physician. So even in the absence of a criminal or civil case the physician could end up on the wrong end of a long, drawn out and painful licensure investigation.

There are factors that could lead to a greater risk of legal consequences if they suggest that more force was used than necessary: if the patient dies or has a serious permanent injury, or if the physician has a chance to escape but chooses to stay and fight instead. And yes, gender discrimination may play a role. If the physician is a young twenty-something, male, six foot four inch tall physician weighing 200 pounds and the patient-attacker is a five foot, 125 pound grey-haired old lady, you could be in trouble.

Off the top of my head I'm not aware of any cases where this has been an issue, and in the heat (or rather terror) of the moment I doubt any doctor is going to stop and weigh out all the potential consequences. And even when the doctor has a legitimate need to defend himself there could still be legal consequences, which are not fun even if the doctor ends up cleared of all allegations.

I thought this post might be useful because it addresses an issue that's not usually covered in standard risk management training. Malpractice concerns have gone too far when they lead doctors to think they should allow themselves to be seriously injured or killed.

(c) Copyright: Annette Hanson MD, 2011 [link to original post]

Annette Hanson, M.D., is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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