[Violence, desire and death. Reflections on 3 taboos in psychiatry]

Few studies have assessed the links of violence, desire and death with psychiatry in a scientific way. Doctors are nonetheless regularly confronted with these situations which are particularly difficult to manage. It is not evident that psychiatrists are properly prepared to deal with them. This paper proposes an original analysis of the scientific literature related to violence, desire and death, and compares the attitudes of European and American doctors.

1) Violence: there is definitely a relationship between violence and mental disorder. Psychiatrists are particularly at risk of being assaulted by patients, especially at the beginning of their carrier (almost 50%). Violence also includes verbal and non-verbal threats, particularly in the emergency department. Psychiatrists are poorly trained to deal with this. 2) Desire: desire is widespread in psychiatry, and can lead to sexual contact between the patient and the therapist in 7 to 10% of cases. The outpatient setting carries the greater risk. Professional associations unanimously disapprove of such conduct but the ethics of posttermination sexual contact remains controversial. Sexual harassment of female doctors by patients is another form of desire (and of violence). Psychiatrists are also poorly trained to deal with desire. 3) Death: acute death occurs in psychiatry (e.g., suicide, substance intoxication and withdrawal, delirium, neuroleptic malignant syndrome, anorexia nervosa, dementia, lethal catatonia), and there is also a link between mental disorder and a higher incidence of natural mortality. Psychiatrists may thus be confronted with death, and the inpatient setting carries the greater risk. They are nonetheless poorly trained in thanatology.

Psychiatric residents need better training to manage violence, desire and death. Poor training results in their exposure to dangerous situations and in inappropriate reactions. Acute management and primary prevention are needed. Acute management should include a collegiate approach, in order to avoid being the "target" of the patient or his/her family. Primary prevention comes through the breaking of the taboos which are still too frequent in Europe, even though the situation is different from the USA. It is important to lay down limits between psychiatry and violence, desire and death. Those situations should before all be better understood, and thereby research in this field have to be stimulated. The holding of consensus conferences in Europe is also important.

There is an intimate relationship between violence, desire, death and psychiatry. This relation is too often neglected, as the poor training of psychiatrists underlines. The nature of the patient-doctor relationship have to be redefined according to those considerations.