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Introspections   |    
The Illusion of Safety
Glen O. Gabbard, M.D.
Am J Psychiatry 2004;161:427-428. doi:10.1176/appi.ajp.161.3.427
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As I thumbed through the magazines on the coffee table in the orthopedist’s waiting room, I found myself wondering why they were restricted to the outdoorsman genre—you know, Field and Stream,Fly Fisherman,Men Who Go Hunting With Other Men to Get Away From Their Wives During the Weekend, etc. I suppose I was feeling a bit fragile, having just had my thumb broken by an assaultive patient. I was the medical director of the Menninger Hospital at the time of the assault and had reasoned that assaults were much more likely to come from staff members who didn’t like my administrative decisions than from patients. Hence, I was caught off guard by the incident, and I was struggling to process what had happened while waiting for the orthopedic surgeon to see me.

The patient who had broken my thumb was a small, frail-looking woman in her 20s who had been referred by a friend and colleague from another city. She and her mother had come from another country to visit the hospital to see if it would be suitable for an extended stay. I had met with them briefly when they arrived and had suggested that they have a look around. After touring the hospital grounds with one of our representatives from the admissions office, they returned to the waiting room outside my office. My assistant told me that they wanted to talk to me, so I ambled out to the waiting room to see if I could be of help.

The patient told me that she had seen the hospital and decided that she would like to live on a houseboat while in treatment. The request was not one that I had expected, so I was a bit taken aback. Topeka, after all, is a landlocked city. I explained to her that it wouldn’t be possible to accommodate her request. She then looked at me in a menacing way and asked, "Are you proposing marriage to me?" Although the situation was filled with uncertainties, I was clearheaded about one thing: I was not proposing marriage to her. I told her so, and she came at me with several swift karate kicks, one of which hit me in the right thumb.

Fictional depictions of violent encounters suggest that time is supposed to slow down during such events. Unfortunately, I could detect no difference whatsoever in my internal sense of time. Only 2 weeks before, I had been lecturing on the management of violent patients to the second postgraduate year residents in my hospital treatment course. I emphasized to them that it is best to ask the patient to sit down and talk, while also taking a seat oneself. Having (for once) paid attention to my own lecture, I invited her to sit in one of the chairs in the waiting room, and I sat across the room in another. We stared at each other suspiciously while I tried to collect my wits, and before I knew it, security guards arrived and escorted her off the campus. My assistant asked me if I was OK, and I assured her that I was. A supervisee of mine arrived in the waiting area, and I took him back to my office to start supervision. He asked me what had happened before the supervision, since he saw the patient leaving the area with security guards surrounding her. I told him it was just a minor assault, certainly nothing to worry about. However, as he started telling me about his patient, I noted an accelerating pain in my right thumb. I must have appeared distracted because after about 15 minutes, my supervisee suggested it might be a good idea for me to go to radiology and have my thumb X-rayed. I followed his recommendation, learned that there was a fracture in my thumb, and drove to the orthopedist’s office.

I emerged from the orthopedic surgery clinic with a cast on my right hand, preventing me from writing my name, buttoning my collar buttons, or winding my watch and forcing me to operate the television remote control with my left hand.

Each time I felt a twinge of irritation about the cast during the next 6 weeks, I also found myself doing a bit of soul-searching. Was I responsible in some way for the patient’s assault? Should I have anticipated it? No, I reassured myself; I had no reason to suspect that she was violent. The colleague who referred her had said nothing about a potential for violence when he called. Did I provoke it? Should I have said "Yes" or "I don’t know" when she asked if I was proposing marriage? Should I have sat down from the beginning of our conversation in the waiting room?

I also thought about my lecture to the residents on preventing violence. Was there a secret omnipotence to the idea that we could do things or say things to keep someone else from being assaultive? Was I forging an illusion of safety and control in a profession in which we really can’t predict what anyone is going to do in our offices, hospitals, or clinics?

When I returned to my class the next day, I was haunted by feelings of embarrassment and self-consciousness. The cast on my hand made me feel a bit foolish. The residents couldn’t take their eyes off it. It was like broadcasting the fact that I could teach principles of violence management to my residents, but when push came to shove (no pun intended), we were all vulnerable to the vicissitudes of fate and bad luck.

I never heard from the patient or the mother again. No phone call. No letter of apology. No inquiry about how I was feeling following the assault. Did they wonder if I had been injured? Did they care?

Years have passed since then, and my thumb has healed. Once in a while, though, on a cold, damp night, a flash of pain emanates from my thumb when I turn during sleep. As I emerge from my slumber with my guard down and my defense mechanisms inoperative, I am reminded of the irreducible fragility that we carry with us into our offices each day. No wonder we write books and articles on psychiatric strategies designed to prevent violence. As Cervantes would argue, illusion is our most profound psychological need.

Address reprint requests to Dr. Gabbard, Baylor Psychiatry Clinic, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 6655 Travis, Suite 500, Houston, TX 77030; ggabbard@bcm.tmc.edu (e-mail).

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