Hektoen International

A Journal of Medical Humanities

It’s not the patient who hit you…

JP Sutherland
North America

The Entombment. Oil painting by Federico Barocci, early 18th century. Victoria and Albert Museum.

Although Christopher’s appearance was extraordinary, there was no sign (not even in retrospect) that he would kick me in the groin within the next hour. He was naked, and standing motionless with his arms held out perpendicularly from his sides. If anyone tried to cover him with a blanket then he would shrug it off again, and resume his original posture, nude. His face was tilted upwards, and a beatific smile danced on his lips. Since the only item on him was a crucifix around his neck, which his stance echoed, and because this was the very early hours of Easter Sunday, there was likely a religious element to his presentation. I would happily have sat and talked to him about this. However, not only was he mute, but he was standing in the middle of a busy emergency room and causing a practical problem for traffic. When the ER’s charge nurse saw me appear, she let me know all about it.

“Thanks for coming so quickly,” she finished, and then called out to her colleagues, “Psychiatry is here, they’ll deal with him from now on.”

Whereupon a couple of ER staff promptly moved on to see other patients, leaving me and Christopher together, and with Mike from security standing like a guardian angel behind me.

I was flattered by being seen as “psychiatry” and representing the whole profession, but the truth was that I was only halfway through my training. I had become comfortable attending the ER for the all too frequent tragedies of psychotic breakdowns and suicide attempts, but this was different. Manic catatonia (if that was indeed to be Christopher’s diagnosis) was something I had only read about in textbooks. The police reported that he had been found in the middle of the road at midnight, in the same posture, and wearing the same amount of clothing. His chart said he was a teacher, and had been in the ER before for broken ribs, but no past psychiatric history was listed.

“How’s it going, Doc?” asked Mike.

By now I knew him and his security staff colleagues well enough to be able to translate his comment into “That’s enough standing around, we need to get him settled and then we have other calls to attend to.” And he was right. I gave the order for sedation, restraint if needed, and transfer to our inpatient unit, and then watched as the injection was drawn up and the staff assembled. Christopher watched too, but otherwise he remained mute and static. At least he did until the three security staff took his arms and led him to a bed. At that point he regained some of his strength. I had seen a few takedowns of uncooperative and belligerent patients, and I could see that this was going badly. So, being the naive young doctor that I was, I took hold of his free ankle and helped. At least that was the plan. But Christopher easily slipped out of my grasp, and his next kick scored a bullseye right between my legs. The next thing I remember is sitting in a chair on the other side of the ER, with Mike looking down at me.

“Are you OK, Doc?” he asked, and his obvious concern couldn’t completely hide a slight grin. “Best leave the rough stuff to us in the future, heh?”

Testicular trauma is a subject that tends to raise a chuckle, and writing about it all these years later I still find myself mirroring the half smile on Mike’s face as he checked in on me. But once the laughter fades the ugly facts remain. Violence is a serious problem for psychiatric patients, public safety, and the healthcare staff involved. The amount of violence is a real concern in itself, but the public perception of mental illness as dangerous compounds the problem.

Physicians are victims of assault more than the general population, and it is a genuine occupational hazard of our trade. Emergency room staff and mental health workers are most at risk, being assaulted on average five times more frequently than the average citizen. Putting it another way, over the course of their careers, almost one in two psychiatrists can expect to be assaulted. The risk is highest in the earlier years of someone’s professional life, which speaks to inexperience, and fits with my enthusiastic but unskilled attempts to restrain Christopher.

Since the public perception of violence amongst the mentally ill is strongly overblown, I have always tried to reduce people’s irrational fears, as part of working to reduce the stigma that impacts my patients. So, in order to counter that, I need to tell the end of Christopher’s story.

He was then cared for by a different team, whose junior doctor was my colleague and friend, Jonathan. Jonathan later told me that Christopher’s illness was indeed a first episode of a bipolar disorder, with the rare addition of catatonia. He had believed that he was specially chosen as the Lord’s favorite disciple, and he was standing in the form of a cross in anticipation of being taken up to Heaven. Christopher was improving as expected, so I returned to my own caseload, and put him out of my mind. But a couple of weeks later I was walking out of the ward on my way to lunch when I stopped short, seeing him standing across the corridor. He looked well, and clothed, and yet I couldn’t help taking a step backwards.

“Dr. Sutherland?” He asked. “I’m Christopher. I think we met in the ER.”

“I remember,” I answered, hopefully avoiding too much emphasis on the last word.

“I wanted to apologize for what happened. They told me that I lashed out and I might have hurt you. Are you OK?”

“Er—yes,” I managed to say, but was wholly uncertain about what to do next. Was he recovered? Was I going to be assaulted again?

Fortunately, Jonathan then wandered along the corridor and, seeing us talking, he stopped alongside us.

“Christopher had said how much he wanted to apologize,” he said, “so I’m glad he found you.”

With Jonathan alongside as a chaperone we managed a short conversation in which I gathered Christopher was fully recovered, had wholeheartedly taken on board his new diagnosis, and was determined to keep it under control with lithium. He apologized for the assault more times than was strictly necessary, and then left.

“He seems like a really nice guy now that he’s well,” said Jonathan.

“Yeah, probably,” I replied.


“It’s just that I’ve never been assaulted before and so I’m not sure how I am supposed to feel towards him. I notice I’ve become more vigilant and less trusting since I was kicked.”

“That’s understandable, but you can’t let it go on too long like that.”

“But how do I change?”

“Here’s what helped me after I got punched last year. It’s not the patient who hit you…” he began, and then proceeded to tell me the mantra that would not only help me in the future, but can also help anyone come to terms with violence that results from individuals struggling with mental illness.

“You have to separate the individual from the illness. People are not defined by their diagnoses, so you should never think that it was the person who hit you, but the illness.”

JP SUTHERLAND (a pseudonym) has come late to writing after a long career as a psychiatrist. His first work is being published in Ars Medica and The Examined Life. All characters are composites from different patients he has cared for over many years. Identifying details have been changed to preserve patient confidentiality, and these include the names of all individuals, as well as the author’s.

Highlighted in Frontispiece Volume 15, Issue 2 – Spring 2023

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