When a Patient Makes Threats

As a psychiatrist, the first rule of treatment is to establish a therapeutic relationship with the patient. Indeed, the need for resolution of doctor-patient conflict is so common for psychiatrists that we give this process a name: “successful resolution of the transference.”

However, one of my cases in particular comes to mind. “Carl”* was a big man, so when he threatened to throw me through a window, it got my attention.

I had cared for Carl in the hospital psychiatric unit when he was admitted through the emergency room with homicidal ideas. He was an imposing figure at 6’3” and 300 pounds. Carl had bipolar disorder and, from his experiences in Vietnam, posttraumatic stress disorder. This left him with potent anger and violent thoughts. Any little conflict caused immediate images of smashing the other person’s head or breaking his bones.

His case was further complicated by stroke-like paresis in one arm, or sometimes in one leg. A complete neurological work-up was negative. I concluded that Carl’s unconscious mind was shutting down parts of his body so that he was unable to act on his persistent violent thoughts - a classic case of conversion disorder.

Carl was surprisingly insightful and benefited from both psychodynamic interpretation and mood-stabilizing medication. After 10 days Carl felt enough control of his violent impulses that he was able to be discharged from the hospital, with follow-up at my office the following week.

But at the follow-up visit I found that while Carl’s conversion symptoms were gone, his violent impulses were back. Carl sat beside my desk. At first he seemed OK, but as we talked about his life, his face reddened and his breathing became more forced. He was getting angry. Then he said, “Doctor, right now I want to pick you up and throw you through that window!”

The window behind me did not open, it was on the second floor, and Carl appeared to have the physical ability to carry out his threat. So this was not good. I managed to keep him talking instead of acting, but afterward I felt shaken and unsure if I really wanted to see him again at our next appointment in one week.

I stewed about it over the weekend. This is a sticky situation for a doctor. I didn’t want a violent person in my office, but I couldn’t just abandon a patient, either. And he didn’t seem bad enough to force him back into the hospital. So when I got back to the office on Monday, I decided to call him.

Carl was surprised to hear from me. I decided to forego any psychodynamic talk and to speak straight to the issue: “Carl, at our last appointment you said you wanted to throw me through the window. Now I’m afraid to see you again. This is just a private office. We don’t have a security staff. We’re not set up to deal with violent people.”

Something about that direct and honest approach caused an immediate change in Carl’s attitude. Perhaps now he was able to see me as vulnerable instead of as an authority figure. (As you might expect, Carl’s father was abusive.) Whatever it was, at that moment Carl changed from a grizzly bear to Wally Cleaver.

“Gee, Doc,” he said, “I understand. You don’t have to worry about me ever becoming violent in your office. I hope you’ll still see me.” I said I would, for now.

That was 15 years ago. Carl still sees me at the office once a month. He gets maintenance electroconvulsive therapy for his bipolar disorder from another psychiatrist and I prescribe his medication and provide supportive psychotherapy.

Since that telephone call, there have been a few rocky times, and even angry and violent imaginings, but no threats or strong impulses to act out. Carl has completed a master’s degree in psychology and has remarried. He now talks about what to do for his wife on her birthday and about missing his daughter, who is attending graduate school in Chicago. I look forward to his visits.

I learned that a telephone call is a useful method of communicating with a patient when physical proximity may be dangerous. An occasional unexpected call to a patient communicates caring and can enhance the therapeutic relationship. And I learned that a direct expression of my own concerns can sometimes humanize the physician, and soften a doctor-patient relationship.

The comfort of our relationship has helped Carl to heal and grow. As I now realize, that telephone call not only helped me feel safe, but it helped Carl feel safe, as well.

* Name has been changed to protect anonymity.

Dennis Helmuth, MD, PhD, is a Distinguished Fellow of the American Psychiatric Association. He and his wife, Kathy, a pediatrician, have lived and practiced in Wooster, Ohio for 20 years.

This article originally appeared in the June 2009 issue of Physicians Practice.