Dangerous people

The police brought a young man who had self-harmed and threatened suicide to the ED for assessment and treatment late at night. They had tasered and handcuffed him in order to do so. He had cut himself 21 times, none of them serious and the worst of them the instant he was shocked because “he lost control”. Only two lacerations were sutured. And he had never cut himself before.

 

He had acted impulsively after breaking up with his girlfriend of 6 months.

 

He was an angry young man professing depression with an energy and animation uncharacteristic of depression. He had also cooled down and although still upset about the break-up had decided to speak to his girlfriend rather than kill himself or otherwise harm himself. My assessment, credible as he was, was that he was not at immediate or high risk of self harm and that he could be assessed by a member of the mental health team in the morning (normal business hours).

 

The offsite supervising officer in charge was not happy with my assessment and instructed her officers to arrest my patient and take him to a psychiatrist to assess him which would involve taking him to the psychiatric hospital where they would be directed to return him to the ED where a psychiatric SHO would come to assess him. It seemed to make no difference to her that a second assessment several hours later would be by a junior doctor with considerably less experience of self harm and dangerousness.

 

Assessments of dangerousness are probabilistic, difficult, inexact and often no better than chance. The variables that contribute are numerous and unstable and like predicting the weather become meaningless beyond the immediate future. Some things make prediction easier: a history of violence; acute psychosis; drugs and alcohol; and severe antisocial personality disorders.

 

Most cases like this one do not have obvious predictors and so the assessment is made on the basis of the lack of predictors, the patient’s stated intent, observed impulsivity and self-regulation, level of emotional arousal and my own improvised provocations over a relatively long period of time: hours rather than minutes. Prolonged exposure to many dangerous people over many years also helps build a tacit model of the dangerous.