Aggressive behaviour in psychiatry: hermeneutic approach as risk prevention mean and as key to professional liability training judgment

Abstract

Diagnostic and clinical case histories in psychiatry are manifold and they range from schizophrenic forms to personality disorders, from mood to anxiety disorders, from sexual dysfunctions to paraphilias, from posttraumatic stress to adjustment disorders, to the organically determined mental disorders. Each one of the cited cases has a different intrinsic potentiality to act aggressive behaviours, anticipated and expressed by different symptoms and signs. Furthermore, we also have to consider the subject’s personality, culture and actual situation, in addition to the personal response to therapy and to operator. There is no doubt that the onset of a violent behaviour is an emergency clinical situation, but the management of aggressivity requires an intervention protocol, which is to include both an analysis of the patient’s resources and of the environmental means, and a precise close examination of the risk, and an accurate search for a risk-benefit counterbalance in every therapeutic option, in the wider perspective of taking the patient properly in charge all through the various phases of diagnosis, therapy, prognosis and rehabilitation. We hereby aim at propose a hermeneutic approach to the psychiatric management of aggressive behaviour, because it may become a necessary therapeutic mean in the doctor-patient relationship, and also because it may give, even later on, a key for evaluating the particulars of a possible professional liability of the medical professional. In fact, psychopathological states are likely to turn into a violent acting out, be it against self or against others, which must be prevented as much as possible with the aim of safeguarding the patient right to his own healthcare, and also to avoid a professional liability of the therapist. The latter, in fact, is in charge not only of the task of diagnosis, but also of prognosis and prevention, in the wider perspective of the taking in charge of the patient, and this in order to grant him the already mentioned right (sanctioned by the Italian Constitution, Art. 32), and even to protect the medical operators, and the possible third parties, in case of destructive behaviour performed by the patient. A hermeneutic approach is intrinsically addressed to the interpretation of phenomena and thereby to the search of their meaning, that’s to say to the explicitation of their implicit significants. This kind of approach may be really important in a prevention perspective: when the therapist relating with his patient searches for the sense of the latter’s aggressivity, he has even the chance to see whether there’s a risk of an acting out. In this way, the professional has enough time to adopt proper prevention measures, with the only aim of the patient’s healthcare. At the same time, this would give the professional a way of recognizing those elements which make it necessary for him to act in compliance with the obligatory means, while evaluating the predictability and the prevention of the illicit event. We also wish to remark the important influence of hermeneutics on other scientific disciplines, such as psychoanalysis (sharing with it the same attention to the symbol, to the language, and to the content of the patients’ clinical histories and to what lies beneath inexpressible) and psychotherapy, since in every clinical dialogue we can build up meanings in common, which can be recognized when put in a context where the different pieces fit together thanks to the whole of the discussion. In this perspective, a hermeneutic approach in the therapist-patient relationship can give valid knowledge for a well grounded prognosis, but also for starting an effective prevention, which may even be able to protect both the patient acting an aggressive behaviour (and the possibly involved third parties), and the specialist from the possible particulars causing a professional liability.