Violence and Survival: Denial and the Ultimate Threat

Although recent news portrays general violence as on the decline, the Centers for Disease Control still rank health care providers only one notch below convenience store clerks and taxi drivers at risk for homicide.

Mental health personnel are exposed to these ultimate threats in emergency rooms, on home visits, walking through lonely hospital corridors or hotel corridors during conventions, as well as on the street and at home. These ultimate threats are not on the decline. Here are two examples:

After a long day at the workplace, in this case a hospital, the young mental health worker heads for home. On the way she stops for groceries. They are placed on the back seat and she drives the several blocks to her apartment house. She fumbles with grocery bags and door key, sets the bags on the kitchen counter. She turns to retrieve the key and lock the door. And there he is.

Later, the police would describe the trail of buttons leading to the bedroom. They were torn from her blouse as she was dragged through the apartment. The police would describe how her body was found in a pool of blood on the bed. She was stabbed 23 times after she was raped.

She had been an experienced psych nurse. She was skilled in observing the clinical course of aggressive, potentially violent psychiatric patients. She knew to stay four feet outside a patient's private space, to approach on a bladed angle for safety. She knew about panic buttons and when a show of force was indicated. Once, she took part in a staff takedown of a violent patient. And several times she recognized her fear of certain patients and asked for consultation. She was well-trained. But not trained to survive on the street or in her own home.

Nor do mental health workers always survive in the workplace. A psychiatrist was in his hospital office when the patient, about whom the doctor had written a not-fit-for-duty report, walked in and shot him dead. He also shot and killed a psychologist in the next office and several others in the hospital. The physician had time to push the panic button. He made an attempt to talk to his killer, to deescalate things. It didn't work. In spite of the violence in-the-workplace protocol the staff was taught, no one noticed the killer walk across the hospital parking lot and through the hospital carrying a rifle.

Are we preparing mental health workers to survive an ultimate threat? Threats which explode terrifyingly, violently and seemingly out of the blue?

Experience in military, police and civilian lethal threat training includes methods which are simple, easy to learn and effective. As an instructor in several self-protection disciplines, I know there are techniques to protect oneself from severe harm, rape and death. The main reason they are not taught to mental health professionals is denial.

Fear-induced denial is a well-documented phenomenon. Hackett and Weisman discussed the denial of fear of heart attack and cancer in 1969. The fear of death by murder, the fear of mutilation, the fear of rape and of violent assault is no less than that of a heart attack. Mental health workers, even those engaged in studying and treating violent patients, are not immune. They are much like the cardiologist who reaches for antacid instead of getting to the emergency room.

If further rationale for better instruction in self-defense is needed than merely to avoid rape or death, it is provided by Phillips and Rudestam, Temple and others. They have demonstrated significant beneficial effects of such training in general clinical care. The staff which receives even a modicum of self-defense training experience a decreased number of patient assaults along with fewer staff and patient injuries.

Denial is not all psychological. Walter Cannon, M.D., described the psychophysiologic reaction we know as the fight or flight syndrome in 1932. He either did not appreciate what every hunter knows, or else he was suffering from denial. Humans, as well as animals, often freeze when terrified. That may be why they say on TV, "freeze" when they don't want the suspect to fight or flee. It could be called the fight, flight or freeze syndrome.

A young nurse did take a cottage industry self-defense course. She carried mace and kept a low profile. She was taught not to resist when attacked. She was not prepared for the reality of sudden, vicious attack; the force and the terror. The attack came suddenly. The nurse froze in her tracks, like a deer startled by the glare of a car's headlights. Her startled neurocircuitry responded as programmed by nature, and like the deer, she was motionless as she was ravaged and killed.

The underlying brain anatomy and physiology of fear arousal has been well-described by LeDoux JE, Also by Adolphs and colleagues. The amygdala, the lateral geniculate bodies and their connection to the midbrain and hypothalamus have been traced. They function in the unconscious processing of startle response and fear arousal. They explain why our scared bodies react before our neocortex knows what is happening.

The unconscious processing of fear sets off a variety of autonomic reactions. Among them is the outpouring of adrenaline, resulting in abnormal strength. The stories about little old grandmothers lifting four-wheelers off their grandchildren are true, and this unusual strength has been utilized by police and military experts to devise techniques effective in the stress of combat.

These techniques help overcome the loss of fine motor coordination during stress and direct gross motor strength into self-protective movement. They do not require superbly fit muscular specimens. They do not require daily combat or martial arts training. Consider this: the average police officer usually goes through training only once. He is probably not as physically fit as a mental health worker who more likely runs, jogs, plays handball or tennis or golf. He is more apt to be middle-aged and overweight. And the officer is frequently female, with less upper body strength. The point is: effective, nonlethal techniques have been devised for these officers.

Another type of denial commonly experienced with a sudden terrifying attack is neurosensory distortion. That is something police survival training experts know a lot about. A security guard did witness the psychiatrist's shooting. He saw the entire event--in slow motion. The technical term is psychytachia. If someone ever took a swing at you, it might have seemed like minutes, not a split second, until it landed on your jaw. If you ever saw a baby topple out of its high chair, it may have seemed like forever before she hit the ground.

The guard also saw the rifle and thought it too big to be real. At the same time, he couldn't divert his eyes from it. He didn't remember hearing the shots. These distortions frequently occur in life-threatening situations. They are known as tunnel-vision and auditory exclusion.

These distortions probably occur in the cortex as types of optical and acoustical illusions. Our perceptions are profoundly shaped by the emotions and context in which they happen. Do you know, for instance, that the setting moon appears huge on the horizon only because we're not used to seeing it there. No, it isn't some light wave refraction effect. Try looking at it backwards, from between your legs. Of course, we don't remember the moon that way.

The police experts who give expert testimony in court about such things know that training and awareness are directly related to the type and intensity of such sensory distortion. They also know that training, even infrequent and simplistic, helps overcome the freeze reaction. Faced with overwhelming fear, the body reflexively responds as it was trained. Yes, even simplistic training. "Hit the dirt!" Ask any combat soldier.

The first technique in learning to overcome denial--to survive without turning homes and offices into fortresses, earning a black belt in karate or becoming paranoid--is learning about condition yellow.

Condition yellow is police and military code for a special state of alertness. You are aware of what is in front, alongside and behind you at all times. Sound familiar? Condition yellow is the level of awareness required to safely drive a car. It also happens to be a very healthy physiologic state. You are more likely to truly notice the roses. In driver education, they teach you what to look out for. Stop signs. Kids on the street. To be safe in our homes, offices and on the street, we should be taught additional warning signs. They mostly have to do with predatory behavior.

The second step in simple defensive training is to be sure it is given by an experienced expert. They are more likely listened to and less likely to give false advice than a novice or cottage industry self-defense instructor. Why else are experts sought for grand rounds or major seminars?

Another important ingredient is that the training needs to be done "hands on." Walking through hypothetical, situation-specific scenarios is particularly effective, and a few easily learned skills and responses are not readily forgotten. They can be reinforced by visualization exercises which can be done anytime. Olympic athletes do that.

Did the psych nurse pay attention to the guy in the store who seemed interested in her, or bumped into her, or asked her for the time? Did she notice the car following her home? What could she have been taught about not leaving a key in the door? You wouldn't do that in your car. Did she know that an ordinary spring door lock is just as important as a dead bolt (she had been taught about dead bolts) so a door could be kicked closed behind you and be locked. All of her training in how to manage assaultive and potentially violent patients in a relatively structured environment did not keep her alive.

Was the nurse who froze in her tracks alert to the man who seemed out of place in the lonely hotel (or was it a hospital) corridor? Had she practiced screaming and what to scream? "Fire!" and "911!" are better than, "Help!" "Help!" is like a car alarm going off on a busy street. Unless you have practiced this you likely can't speak, let alone scream when being raped, and you certainly can't scream, if your own protective mace is being sprayed in your face. Why didn't her self-defense instructor tell her that she was less likely to be injured or raped if she resisted, or how to resist? Sometimes an in-your-face aggressive command is more effective than a karate chop.

And what of the two doctors shot in their hospital offices? A not-fit-for-duty report should have been a stop sign sent to security and everyone working in the area. Did the doctors know that people with guns are in a high state of stress, and can be distracted and disarmed? Had they been taught that you can survive if shot, and what the various odds are? Had they even once gone through a mock training session with this scenario? Training should address these questions and include going through those hypothetical mock exercises with coworkers.

Was anyone there trained, including the security guard, to yell, "Gun! Gun!" when they spotted the weapon? Yes, just like the police do in the movies. They do it in real life too, for good reason.

Do you need special forces training to survive attack by gun or knife? No. You need to be able to assess the situation. You need to have walked through it. You need to know whether distraction or disarming is possible; to know that several people might be able to overwhelm an assailant; that rifles in particular are not difficult to take away. Not special services, but a raw recruit can do that. It happens rather frequently, but doesn't generally make the evening news.

Sometimes it's best to sit there and do nothing. Sometimes you'll just sit there--forever. Sometimes it's best to take a chance--to end up wounded but alive, or at least to save the lives of others.

The police have a saying, "Keep the Walls Bare!" No more memorial plaques. Mental health workers should have a chance to do the same.

References:

References

1.

Adolphs R, Tranel R, Damasio H, et al. Fear and the human amygdala. J Neurosci. 1995;15(9):5879-5891.

2.

Cannon, WB. The Wisdom of the Body. New York: W.W. Norton; 1932.

3.

Diamond B. Violence in the accident and emergency department. Accid Emerg Nurs. 1994;2(3):172-176.

4.

Hackett TP, Weisman A. Denial as a factor in patients with heart disease and cancer. Ann N Y Acad Sci. 1969;164:802-817.

5.

LeDoux JE. Emotional memory: in search of systems and synapses. Ann N Y Acad Sci. 1993;702:149-157.

6.

National Institute for Occupational Safety and Health. Current Intelligence Bulletin 57, June 1996.

7.

Phillips D, Rudestam KE. Effect of nonviolent self-defense training on male psychiatric staff members' aggression and fear. Psychiatr Serv. 1995;46(2):164-168.

8.

Temple CM. Managing physical assault in a health care setting. Rehabil Nurs. 1994;19:281-286.