Iran: Lessons From the Locked Psychiatry Unit

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Part of my residency training in psychiatry was spent working on the locked unit at the Shattuck State Hospital in Massachusetts. It was there that I learned strategies to keep people safe when voices or visions or delusions made them threaten others with harm-whether verbally or physically. The strategies were very important, because some of the folks on the unit had never been violent, while others had been court-ordered to the Shattuck after committing very violent crimes, including murder. We needed to protect not only the staff, but patients, too.

The lessons I learned at the Shattuck are ones that the Administration should keep in mind in dealing with Iran. After all, Mahmoud Ahmadinejad appears either to be a pathological liar with extremely violent intentions and a willingness to distort history or to actually be delusional. In either case, he qualifies as an inpatient on a locked psychiatric unit.

Here are lessons from the Shattuck_

1. It is highly desirable to listen to every patient, even those with delusions, because their truth may be audible, despite the content of their speech being insane. Someone with grandiose delusions, who believes he is the savior of the planet, may actually be expressing deep feelings of low self-esteem. Similarly, the desire to obtain nuclear weapons and destroy one's neighbors may relate to internal feelings of having been annihilated. So it may be with Iranians, whose self-esteem and willingness to be led by a madman (notice the contracted words mad and man), may reflect their internal feelings of vulnerability.

2. When a delusional or violently ill patient seeks to arm himself, he is to be watched extremely closely and repeatedly searched. There can be no negotiation on this account, as the violent or delusional man cannot be trusted.

3. When the delusional or violently ill patient is found to have secreted away a weapon, it must be presumed that he fully intended to use it and that he will be very angry that he cannot. Therefore, he must be rapidly disarmed and then placed in quarantine, lest he either rearm himself or attempt to show his strength using his fists or a discarded needle. On a psychiatric unit, that means a room search, confiscating any weapon and placing the patient in the locked quiet room. In Iran, it means destroying Iranian nuclear facilities, then isolating the country, then searching for any other threats.

4. Psychiatric patients at the brink of violence are not comforted by, nor dissuaded from that violence, by quiet speech or bargaining. They are comforted by a show of force that convinces them that they are better off in the good hands of a healer than left to the chaos of their own intentions. Even four-point restraints can be a comfort to a man out of control whose mind knows not the limits of rational thought and action.

5. Time is of the essence. When a psychiatrist on a locked unit feels a patient is about to become violent, the thought processes inside that patient often have been brewing for a very long time. At that point, making the unit safe has to precede more elegant attempts at healing.

6. The other patients are watching. This means that the psychiatrist's response to a violent patient will either quiet the unit (for which you may read the Middle East) or inflame it. Permissiveness is always perceived by the unstable as a call to chaos.

7. Always read the clinical history of every patient for any past episodes of severe violence. The past is a good indicator of the future, even when great progress would seem to have been made. Witness the recent embracing of terrorists by Muammar el-Qaddafi.

8. Keeping the unit safe is not about hating anyone. Even the violent patient is a worthy human being at the core. But that does not mean that the patient is not a grave risk to himself or to others. There can be no fear of taking action, nor any joy in doing so.

As it was at the Shattuck, so it is in Iran. I hope Dr. Obama is listening.

Dr. Keith Ablow is a psychiatry correspondent for FOX News Channel and a New York Times bestselling author. His book, "Living the Truth: Transform Your Life through the Power of Insight and Honesty" has launched a new self-help movement including