The Minneapolis StarTribune posted a recent story about the Minnesota Security Hospital (MSH) on December 27, 2013 that was updated today. The article raises concerns about patient treatment and safety at this facility both for patients and staff. It should be read by everyone with an interest in how state mental hospitals function. It is of particular interest to Minnesota residents who may have a relative being treated at this facility but also anyone concerned about the image of the state and how it treats residents with severe mental illnesses. From a policy standpoint it should be an issue of great importance for both local psychiatric societies and the American Psychiatric Association (APA).
Let me preface my remarks by saying that I have no inside knowledge of what is occurring at the MSH beyond what I read in the papers. The first concern is about the information base for the article and who is interpreting that information. That is contained in the fourth paragraph of the article at the very end of that paragraph:
"Nearly two years after the hospital's professional psychiatric staff departed in a mass resignation, the state still has not hired a full complement of psychiatrists, documents show. Basic medical record-keeping has been neglected, employees have been placed in danger and patients have been discharged with inadequate safeguards, according to internal memos, federal records, and agency files reviewed by the Star Tribune."
The problem here is that there is nobody at the Star Tribune who is an expert in the treatment of patients with severe mental illness and aggression. The second problem is that there is a significant conflict of interest anytime a journalist has access to clinical material with a potential sensational interpretation. From my experience journalists will make that interpretation out of ignorance or for the purpose of enhancing the dramatic impact of the story. In this article the names of two patients are disclosed. Journalists are not confidentiality bound to not disclose the names of patients and there may be some public documents with the names of these patients. My experience with journalists has been that they want to talk to actual patients with real names, and really do not understand the problems with that. There are always many potential weaknesses when considering a journalistic source.
There is a precedent for the review of confidential hospital records by expert unbiased reviewers and that was the Medicare Peer Review Organizations (PRO) system. In that process, physicians who were experts in the field in question were rigorously screened for conflicts of interest. As an example, they could not have any affiliation however peripheral with the hospital or clinic being reviewed. The compensation for reviewing the records was trivial and you could not make a living at it. Reviewers were expected to be practicing medicine full time and not be an administrator. As a reviewer, I reviewed tens of thousands of pages of hospital records - many from state hospitals for both quality problems and utilization problems. A newspaper reporter looking at a patchwork of records, memos, and files from multiple sources is hardly an adequate standard to draw any conclusions. A reporter can make it seem like the hospital is a "bad" place for restraining people or in this case failing to restrain a person.
A potentially rich source of information is the hospital's former medical director - Dr. Jennifer Service. She has one quote in the article about how the MSH is "broken", but it provides no details. My speculation is that there is nobody who had a better front row seat to what happened than Dr. Service and possibly the previous medical director. In the treatment of severe mental illness and aggression the medical director or clinical director has a critical role in making sure that there are no administrative factors that adversely affect the treatment team or their ability to provide care and a safe environment. A common mistake is that administration believes it can effect change and they do not pay close enough attention to the impact on the clinicians providing care. When treating aggressive people any environmental change like that can result in increasing aggression and chaos in the treatment environment. The Legislative Auditor's Report suggests several areas where the therapeutic neutrality of the environment and staff cohesion were problematic. During 23 years of conducting team meetings, my experience was that psychiatrists are an integral part of the team and should be the team member most experienced in team dynamics, countertransference, and approaches to violence prevention. There is no indication that occurred on teams at the MSH and in fact, participation is described as marginal.
There are other potential conflicts of interest here that potentially bias the story. Minnesota Department of Human Services apparently administers the place. In this case Commissioner Anne Barry talks about the goal of increasing the likelihood of discharge by making community living environments more available. Since DHS also administers all of those environments in the state it should be a relatively easy task. Why is it not being done? Are there people who realistically cannot be discharged without recreating a hospital environment for them in the community? In the cases where that has happened have there been more adverse outcomes? Are those environments more humane than the hospital environment where the patient was initially? The Deputy Commissioner talks about accountability, but DHS seems like one of the most opaque state agencies out there. Lately they seem to have moved into the area of micromanagement of the treatment providers especially around the issue of aggressive behavior. Are the administrators of DHS responsible for the failed programs at the MSH? Commissioner Barry talks about a more "therapeutic environment". Is she qualified to determine what that is? And finally the Legislative Auditor's Report alludes to a report by previous consultants. Who were these consultants and where is that report?
Another good illustration of how conflicts of interest potentially bias the StarTribune article was the issue of accusations of maltreatment by professional staff. The first is an allegation that a psychiatrist "committed maltreatment" by threatening an uncooperative patient with electroconvulsive treatment. DHS investigators concluded that this happened but their finding was overturned by the DHS Inspector General. The State Ombudsman for Mental Health and Developmental Disabilities apparently believed it happened and made a request for the DHS Commissioner to reconsider the finding. The Inspector referred the matter to the Board of Medical Practice. In the second case, 2 nurses were accused of maltreatment. From the way the article is written it appears to be related to the incident where the patient was "slamming his head repeatedly into a concrete wall" and they were unable to get an order to physically restrain the patient. The nurses were fined and reported to the nursing board. Based on the incidents of maltreatment and another incident where a patient did not receive timely assessment for a stroke the DHS Commissioner extended the hospital's probation through 2014. There are many problems with employees paying the price for chaos in the system. Administrators often do not recognize the professional obligations of the staff. I have personally seen quality psychiatric staff paralyzed by indecision that was brought about by administrative mandate or personnel problems. The other problem here is that DHS appears to be the administrator, investigator and judicial process rolled into one. We have a number of political appointees (DHS, Ombudsman, Board of Medical Practice) charged with deciding the professional fate of a physician who seems to be practicing in the worst of possible scenarios. It should not be too surprising that MSH is unable to recruit and hire psychiatric staff.
The Legislative Auditor's Report is probably a better source of information than the newspaper report, but it has the same lack of input from experts. It is useful from the perspective of bureaucratic information on the details that can be counted like the number of psychiatric contacts, number of hours of therapeutic contact, number of staff injuries for a certain period of time, etc. One of the areas that is most interesting to me as a psychiatrist is the frequency of patient contact by psychiatrists. The report gives an example of a recent census of 321 patients. It provides an exhibit showing that from a policy standpoint the suggested frequencies of contact are monthly, quarterly, or semi-annually. These frequencies are interestingly lower than the frequency of contact in some 19th century German asylums. I can recall that Binswanger made a point of seeing all 200 patients in his asylum every week. The report said that of the 321 patients in the study 45% had been seen in the previous month, an additional 24% 1-2 months earlier, 17% 2-3 months before and 4% greater than 3 months before. Going from a full complement of eight psychiatrists to a total of two psychiatrists and 1 nurse practitioner is an obvious problem in terms of contact. Actual contact with psychiatrist is an insufficient metric for treating patients and other quality measures need to be developed.
If the article and the Legislative Auditor's report are even partially accurate with regard to facts, the glaring problem here appears to be that there is nobody in charge who knows how to run a hospital that treats people with severe mental illness and problems with aggression. It is probably more correct to say that at this point we have not been presented with any positive evidence that there is a person in charge with the necessary qualifications. The information presented in the StarTribune article does not suggest a clash of cultures. There is no psychiatric hospital culture that I am aware of where there is confusion about whether or not a patient should be allowed to injure themselves. The second problem is that this hospital needs psychiatrists who are trained to treat severe mental illness and aggression. They do not need to be forensic psychiatrists, but they do need expertise in treatment of severe mental illness. Forensic psychiatrists are basically needed to perform specific evaluations of criminal responsibility but the priority here is described as patient and staff safety. The people needed in this situation currently work in a number of acute care and community settings. They are very comfortable with the treatment of major psychiatric disorders and the associated medical comorbidity. It is safe to say that they enjoy working with these problems and talking with the people who have them. They are also sensitive to the needs of their co-workers and can establish the necessary environment of mutual trust and neutrality needed to succeed.
There may not be anyone around who remembers that Minnesota has solved a similar problem in the past. The year was 1990 and there were significant problems staffing the major state hospital in the system - Anoka Metro Regional Treatment Center. At that time, a Medical Director who was recently out of training was hired and he hired several colleagues from the same generation. They were all enthusiastic and interested in providing quality care. The state offered them competitive salaries. Within a very short period of time a cohesive staff developed and they became a favored training site for medical students. Treatment at the state hospital improved dramatically and several of the psychiatrists in that cohort went on to become leaders in the state in the provision of psychiatric services to patients with severe mental illness.
That still seems like a good idea today.
George Dawson, MD, DFAPA
Paul Mcenroe. Minnesota Security Hospital: Staff In Crisis Spreads Turmoil. StarTribune, December 27, 2013.
Office of the Legislative Auditor. Evaluation Report: State-Operated Human Services. February 2013.
Additional Clinical Note 1: Looking back over my post it is clear that I do not answer the question that is the title. Like most people I am speculating based on an imperfect data set. The main difference is that I am also speculating as an expert based on what needs to happen to provide the safest scientifically based treatment for people who are mentally ill, aggressive, and may have failed most if not all of the available treatments. I also recall that some past state hospital problems were resolved that has not been brought up in the discussion so far.