There aren't too many retirement parties that you can go to and spend a lot of time talking about violence. I suppose it might happen with law enforcement and the military. When I went in to psychiatry I never seriously thought about the fact that I might have to go to work every day and face people with serious problems with aggression and violence. In some cases that would mean seeing people who had threatened to kill me and my family. It would also mean seeing people with documented incidents of aggression toward others, toward themselves, and toward property.
I went to a retirement party yesterday for a nurse I had worked with in an acute inpatient setting for about 20 years. Like most of the nursing staff I work with she has excellent skills but was also renown for her sense of humor and positive attitude. She was the kind of person I counted on when things were particularly grim - a frequent occurrence on inpatients units. I could only make it to the last 2 hours of the party, so I missed the evening shift who all had to leave and go to work. There were about 20 people there including a psychiatric colleague who worked with me on that unit and who I have known for 30 years. I always consider retirement parties to be very happy events. I have known too many medical professionals who never made it to retirement. I want everybody to make that goal, especially people I have been in the trenches with. I previously posted here many times about the inpatient environment and its importance is treating and containing aggression and how that function has been subverted by political and administrative forces and rationed to the point of being minimally effective. When you are working on an inpatient psych unit, it is a lot like going to war every day. You are facing many patients who don't want to be there despite significant problems. Many are involved in contested commitment hearings based on whether they have a suicide or aggression risk. Many have severe substance use problems that intensify suicidal thinking and aggression. They are generally not interested treatment for the substance use problems or do not see that as a significant issue. There are minimal resources to work with. The team social workers generally don't last too long because there are very few community resources that want to cooperate with discharge plans from acute care psychiatric units. Everyone is working under an administration that is focused on restricting resources and providing suboptimal care. Everybody at that party worked with me in that environment at one point or another for 23 years. At times it was like we were in foxholes under siege for weeks at a time, just looking for a break.
It was good to see everyone in a much less stressful context, but like most groups of people who have been immersed in a high intensity work experience the conversation tends to gravitate back to the humorous and stressful events that we were all a part of. One of the common threads was aggression. I learned that one of the nurses had recently been assaulted and sustained broken nose and a traumatic brain injury. She discussed the incident and her reactions to it. My psychiatric colleague added her personal experiences with aggression directed toward her. As I looked around the room, I was aware of the fact that significant physical aggression had occurred toward about 25 % of the people there. In some cases there were episodes of repeated physical aggression. At some point in my career, I realized that there was really nobody who was interested in helping inpatient staff contain aggression. There are always administrators around who are ready to assign blame. I can remember one particularly unhelpful "consultation" that suggested that the problem was a lack of rapidly forced medications. The most recent administrative initiatives have to do with not forcing anything. Suddenly everyone was supposed to respond to quiet deescalation. Sitting in a quiet office somewhere and looking at spreadsheets does not lead to any insights into containing aggression on an inpatient unit. I guess the typical administrator does not realize that. My realization was that as a team we had to discuss the issues with patients constantly, emphasize the violence risk, emphasize that we did not want anyone to take chances in these situations, and discuss a detailed plan that included ways to approach the patient and their family as much as medication.
About halfway through the party, one of the nurses handed me her iPhone with the the story about a psychiatrist who had shot a patient in a crisis clinic. It reminded me of the time I had to consider about whether or not to arm myself. I was after all a tree hugger and a Child of God from the 1970's. The last thing I wanted to do was have guns in my house. I was aware of psychiatrists who had been killed by patients, in several cases with firearms. I had just read an article about a psychiatrist who was also a Sheriff's deputy who carried a handgun. In my case it was a patient who threatened to shoot me when I was walking out to my car from my clinic. He made the additional threat to burn down my house and kill my family. He proved that he knew where to find me by reciting my home address. Going to work under those conditions every day and treating other aggressive patients is stressful to say the least. But it is expected of psychiatric staff, in some cases even after they have been assaulted and the patient who initiated the assault is still in treatment.
I have no personal knowledge of the shooting incident but the descriptions suggest common system wide issues that are never well addressed these days. Rather than speculate about media reports there are some common safeguards that I have learned apply everywhere and serve to contain violence and aggression in clinics and on inpatient units:
1. The atmosphere - you can't really expect to reduce the potential for violence or aggression unless the environment is adequately managed. Psychiatrists used to talk about the milieu but that ship has apparently sailed. The largest professional organization of psychiatrists is silent on inpatient treatment and the treatment of aggression and violence. The American Psychiatric Association (APA) used to have guidelines on such matters, but nothing has been written in a long time. I don't know if that is just giving up to the widespread managed care blight or an open acknowledgement of the hopeless situation. The APA has been reduced to homilies about how increasing access may reduce violent events rather than speciality units set up to treat aggression and violence associated with severe psychiatric disorders.
Inpatient units can literally be staff on one side of the plexiglass and the violent and aggressive patients on the other. I worked on a unit like that at one point. We were all shocked one day to learn that we really were not behind plexiglass when a steel chair came flying through a shattering tempered glass window. It sailed right over my head and I was standing up at the time. It must take quite a bit of force to throw a steel chair that distance through glass and to that height. Nursing staff dove for cover with the explosion of the glass. In addition to the staff it took two Sheriff's Deputies to resolve the situation. There are any number of reasons given for running units like this and none of them are good. It puts the patients and staff at risk by eliminating one of the most important aspects of psychiatric care - the interpersonal relationship between patients and staff. Without it a correctional atmosphere can develop that is more conducive to rioting than treating mental illness.
That same floor had a history of firearm related events. There was the case of a patient who had a firearm smuggled in. He held the psychiatric resident hostage and ended up shooting a Sheriff's deputy at the control desk out in the hallway. When I worked there, I was surprised one morning to find a number of men on the unit in suits. I learned they were federal agents. I was more surprised to find out they were carrying machine guns. People armed with automatic weapons really do detract from the therapeutic atmosphere of a psychiatric unit.
2. Relationships - one of the most dangerous situations I have ever been in was ending up on the wrong side of the plexiglass at the wrong time. The wrong time was at a time I was being blamed for a staffing problem that I really had nothing to do with. Many people don't know how the attitudes that staff have toward one another can be played out in an intensified version by patients. I found myself surrounded by 4 young aggressive paranoid and antisocial patients who threatened to beat me up. After I talked my way out of that situation, my solution at the time was to transfer off that unit with the idea that I would not let that happen again and hopefully pass that knowledge along to other staff. Unfortunately that same pattern of behavior can occur if it is activated by someone outside of the treatment team. When that happens it is impossible to deal with in a constructive manner.
3. Systems issues - the lack of administrative support for any functional approach to aggression is often the biggest obstacle to solving the problem. This is not an issue in many places where the approach is to kick the can down the road. Many community hospitals don't accept violent or aggressive patients or even patients who are highly suicidal and may require 1:1 staffing. They are transferred to tertiary care centers where these problems tend to concentrate. In those tertiary care centers it is important to segregate patients based on their potential for aggression. I have heard all kinds of arguments against this procedure that do not hold water. I think people may be confused about the segregation issue. I am talking about separating men with a high potential for physical aggression from other inpatients who are generally more vulnerable than the average person. Trying to treat those populations on the same unit is a recipe for disaster. If the most aggressive mentally ill people in the state are being concentrated in a few hospitals, it is the only safe way to proceed with treatment. Even then, there needs to be considerable expertise on the part of the staff involved.
4. Serious administrative deficiencies - I have never seen a clinician with the knowledge required to address any of the above issues in an administrative position. In an a new twist, there are some hospitals where administrators with no experience at all are charged with running hospitals for patients with severe forms of mental illness and associated aggression. The commonest excuse for not addressing any of the concerns on this list is finances. There is not enough money to provide adequate staffing. In many cases there are now elaborate methods to decide on adequate staffing. At times the staffing differences between an all male unit housing patients with psychotic and personality disorders with aggressive behavior is not much different from a mood disorders unit where there is practically no aggressive behavior. Security on the units with a high potential for aggression often depends on other staff being available by cell phone or alarm. In some cases it is a 911 call to local law enforcement. I have had to ask that the 911 call be made when an entire male unit essentially rioted and it was no longer safe for the staff.
5. It is all about the nurses - A key lesson that nobody ever learned in medical school and few physicians seem to learn after is that the only reason anybody needs to be in the hospital is nursing care. Doctors can go in and out for 20-30 minute blocks and write orders, do procedures, and write prescriptions anywhere. The nurses are with the patients 24/7. It follows that one of the primary tasks as a physician is to assist the nurses. That ranges from taking care of medical and psychiatric problems in a timely manner to backing them up in highly contentious situations. Nurses are not there to make physicians miserable. Nurses have an incredibly hard job to do and they know it takes a team effort. There can't be any "personality conflicts". In the interest of the team they need to be set aside.
Those are some of the thoughts I had about this party. Of course I thought about the person being honored and my direct and very positive professional experiences with her.
And I looked around and hoped that everybody there could function as a team, take care of one another, and make it to retirement.
They have nobody else looking out for them.
George Dawson, MD, DFAPA
Supplementary 1: I had thought about posting the following disclaimer at the top of this post:
"In case you thought this was my retirement party and thought you would enjoy reading about that and rejoicing - you can stop reading right here. I have not retired and this blog continues...."
But I thought it flowed better the current way.