Case Scenario

I recently had a patient who I feared had the potential to become violent. This middle-aged man walked into our office without an appointment and asked to speak with a doctor. My receptionist asked if he had ever been a patient with us before. He said no and became somewhat agitated at being questioned.

My receptionist called me out of a room to talk with him. He wouldn't tell me what he wanted, and he seemed somewhat paranoid. My name was on his insurance card, so we made an appointment for him at my next opening. We gave him some demographic and medical history forms, which he filled out only partially, omitting all background history except name and address.

He didn't keep his appointment, but then he came to see my partner for an acute-care appointment, saying that he wanted to lose weight because he was “in the National Guard and needed to meet his weight limits.” He said he used to get his care through Veterans Affairs, but he would not give any past history or background information. He was given a laboratory slip but, on arriving at the laboratory, he refused to let them draw blood.

Later that week he called to make an appointment with me. He told my receptionist that he was extremely upset with how he was treated when he first walked into our office, adding that “no one has treated me like that since Vietnam.” He said that the reason for the appointment was to “talk to the doctor.”

Needless to say, I was somewhat apprehensive about this visit. It seemed to me that this was a secretive, paranoid man who was angry at my office staff and possibly at me. My partner who saw him said he was somewhat agitated and barely in control.

What can a physician do to safeguard himself or herself and the office in a situation like this? The patient again failed to show up for his appointment, but he might make another one. If I discharge him from my practice, he might really go off the deep end.

Commentary

There is probably no situation more difficult for the physician than working effectively with a potentially violent patient. The patient and physician put up barriers that get in the way of medical care: the patient, through his or her hostility, and the physician, through the need to protect himself or herself. This combination of factors can be explosive and lead to deleterious outcomes if not handled with expertise.

It is always helpful to remember that transference and countertransference issues are at play when dealing with hostile or potentially violent patients. The anger and hostility that the patient projects toward the physician (transference) is displaced, in that the anger is not truly about the physician, yet the physician provides a useful outlet for expression at that moment. Hence, the physician should not take the hostility personally. The fear (and, occasionally, anger and hostility) that the physician feels toward the patient (countertransference) is important to recognize because it provides a gateway to understanding the patient's underlying feelings. In my clinical encounters, I have found that the feelings experienced by the physician correlate directly with the feelings experienced by the patient. If the physician is afraid, it is likely that he or she is picking up on the fact that the hostile patient is frightened as well.

Following some simple guidelines can help physicians. Never be hostile toward the patient. It is perhaps the least effective action. Seek to be conciliatory. If there is no immediate threat, consider developing a treatment contract with the patient by describing the acceptable limits of interaction within the physician-patient relationship. Seek to understand the patient's perspective and identify his or her goals for the visit and the overall relationship. Be patient and persistent and involve the patient in planning as much as possible.¹

Finally, it is important to be realistic about potential danger. Despite the best attempts of the physician to reframe hostility as fear and to allow the patient to express anger in a healthy way, occasionally the patient will have developed such impenetrable defenses that his or her projected hostility will not be successfully altered. In these situations, the physician must be sure that he or she and the office staff are protected from harm, even if doing so may lead to further escalation on the part of the patient. Bringing a second staff member into the room might be appropriate. Permission should be sought from the patient because of issues of confidentiality; however, if the patient refuses, the physician can also refuse to proceed with the visit. Common sense should dictate the physician's actions. If a physician or staff member feels threatened, he or she should call for help.

Law enforcement may need to be contacted if an immediate or perceived future threat exists. In the event of an ongoing threat, a panic button may be helpful in certain practices if the anticipated risks are high. Dismissal from the practice should be considered if there are no indications of psychologically healthy responses from the patient.

I find it helpful for my own state of mind to reframe, for myself, hostility and anger as manifestations of underlying fear. From this perspective, the potentially violent patient can be viewed as a patient who is “crying for help” but unable to express the cry effectively. The hostility can then be seen as an expression of the defense mechanism that it more accurately represents. Defense mechanisms arise in the presence of fear. Once the hostility is reframed as fear, the physician is more free to experience compassion for the frightened patient. Often patients who are hostile have a story to tell and a need to be listened to. Compassion and care on the part of the physician can encourage the patient to formulate this story over time, and in telling it, to express anger in a way that is healthy for the physician-patient relationship.

In this particular case, several specific diagnoses should be entertained. The mention of Vietnam certainly suggests the possibility of post-traumatic stress disorder or depression, both of which can manifest as hostility.^2,3 While less likely, the possibilities of borderline personality disorder or paranoid schizophrenia should be considered. Consultation with a psychiatrist or a psychologist can be helpful; however, a successful referral can be achieved only by way of a facilitating primary care relationship. The situation begs for a compassionate stance by the initial physician.