By Shaili Jain, MD

Years ago, the police brought a middle-aged man to the hospital for evaluation on a day when I was the on-call psychiatrist. Earlier that morning, the man had walked into his psychiatrist’s office without an appointment asking to see his doctor immediately. When his demand was not met, he caused a raucous in the waiting room, tossing over tables and chairs and alarming the other patients. He refused to leave, and the police were called.

When I met him, he was red-faced and incensed. I listened to him rant about his psychiatrist, alleging he was responsible for the breakup of his marriage. During a recent couple’s session, he claimed, a clinical observation about the couple’s relationship had prompted the wife’s decision to leave. “I want to ruin his life the way he has ruined mine!” he told me, eyes glaring.

Working with the mentally ill requires a unique form of bravery. One must be willing to wade into the intimate and dark recesses of people’s psyches in order to help them even when it gets messy. I knew the man’s psychiatrist to be a professional, intelligent and sensitive doctor. My hunch was this: The patient’s marriage break-up was so impossible for him to accept that he needed someone else to bear the brunt of his shame and rage.

My somber task that day was to make a risk calculation. How dangerous was this patient? How likely was it that he would actually harm his psychiatrist?

On March 9th, 2018, at the Pathway Home program for returning veterans located on the grounds of the Veterans Home in Yountville, California, Christine Loeber, a social worker and the program’s executive director, Dr. Jennifer Gonzales, a psychologist who was six months pregnant and Dr. Jennifer Golick, the program’s clinical director, were killed by a former patient.

For social workers, psychologists, mental health nurses, and psychiatrists everywhere the Yountville tragedy is igniting conversations about the risks of being intentionally harmed by the very people we are trained to care for.

For many reasons, these conversations are hard to have.

First, mental health professionals have legal, ethical and moral responsibilities toward their patients. Years of training have us primed to act in our patient’s best interests. This philosophy is turned on its head when one is deliberately threatened by a patient. All these aspects leave a professional in murky and unchartered territory.

Secondly, it is how easily lines can blur. It is true that most individuals with serious mental illness are not dangerous. In fact, these individuals are more likely to be the victim of a violent act than a perpetrator. Still, caring for the mentally ill, by its nature, requires compassion for a clientele whose pathologies can render them mistrustful, belligerent and even hostile. Patience is a must when handling their ambivalence or outright rejection of treatment. Tenacity to hang in there is also needed, even when one’s limits are tested by irritable rants.

Successful therapists make an empathic commitment to be a faithful companion on a long road to recovery that can be bumpy. For professionals who are invested in caring for their patients, it can be challenging to identify when a situation has progressed beyond business as usual to the realm of threatening.

Third, risk calculations about a patient’s level of dangerousness are complicated. There are no neat algorithms or absolute answers. No blood tests or brain scans that can pinpoint a definitive statistic. Determining risk is as much clinical artistry as it is science.

Finally, there are wider systemic problems at play. Persistent lack of funding for mental health services, loss of invaluable resources such as in-patient psychiatric beds and mental health professionals being increasingly required to do more with less are all factors that pose additional threats to the safety of a work environment.

Along with being competent in how to diagnose and treat mental illness, today’s mental health professional needs to have the stamina and communication skills to continuously advocate for a safe work environment. This is especially necessary when they are caring for patients in large organizations where it’s easy for the voice of frontline clinicians to be drowned out.

Twenty years ago, I was a medical student who was drawn to becoming a psychiatrist but put off by the dangerous aura that whorled around this unique medical specialty. I was fortunate to receive the collective wisdom of mentors who did not shy away from this difficult conversation. They also reminded me of what I had to lose by walking away.

The wounds of mental illness manifest in a person’s behaviors which to the untrained eye, can be jarring, bizarre and inexplicable. Yet, we mental health professionals are motivated by the challenge of finding keys to unlock the mysteries of the mind and the reward inherent in helping sufferers heal. Mental illness often cuts to the heart of life, interfering with one’s capacity to love, create, and work. In alleviating the suffering of the mentally ill, we also heal families and communities too. Mental illness is so stigmatized that sufferers face endless barriers when trying to get help. Those we care for are also often marginalized and misunderstood by society. Advocating for this vulnerable population is a worthy way to spend a career.

Today, there are thousands of talented young people who are considering a career in mental health. The tragedy in Yountville may give them reason to consider another path. Even though conversations about the dangers of being a mental health professional are difficult, we must have them.

We all have too much to lose if we don’t.