Almost on cue, USA Today came out with a story at about the same time that I responded to a post about secure environments in psychiatric hospitals. My response provided a specific reason why these places need to be a firearm free environment and why armed peace officers sitting at bedside or in the hallway are not really more of a deterrent to criminals with goal directed aggressive behavior or patients with mental illness who have aggressive behavior. My personal experience with firearms in psychiatric settings is fairly extensive. It varies from visiting a primary care physician in his office early in my career and being shown a closet full of firearms turned into him to working in settings where mental health professionals or law enforcement professionals were killed by the use of a firearm. It has occurred in both inpatient settings and outpatient clinics. Even without firearms I have worked on inpatient units with highly aggressive individuals that on several occasions basically rioted and took control of the hospital unit until enough law enforcement staff came on the scene to restore order. In one situation an entire unit was disrupted by one individual and law enforcement had to be called. Against this backdrop, I was more than a little puzzled by new legislation in the state of Texas that allows visitors to carry weapons on units in Texas psychiatric hospitals.
The USA Today article states that although staff and patients are not allowed to have weapons, visitors are now allowed to openly carry firearms. Signs suggesting that these weapons need to be left in cars or concealed needed to be removed. A hospital spokesman quoted in the article makes the understatement of the year by saying that it is generally not a good idea to expose hospitalized patients to weapons of any kind. Even police officers entering these hospitals do not carry in weapons, probably because it is standard police protocol to not carry weapons in an environment where there are large numbers of potentially aggressive people with impaired judgement in close proximity. In my previous post, I also point out that firearms are not a deterrent to people who are aggressive and have severe impairments in judgment or see them as a means to escape or perpetrate violence. Law enforcement officers involved are also not able to maintain a high enough level of vigilance to prevent an unexpected attack. A hospital environment is not generally a very stimulating environment. There may be a significant amount of background noise, but there are not a lot of events that require focused attention - like very low frequency aggressive events.
The best protection against these events are physical barriers to protect people from the aggressive person and maintaining a therapeutic environment with multiple interventions to reduce violence. The barriers include jail cell units where incarcerated patients who need acute medical treatment can be transferred to and entire 18-20 bed units that specialize in treating aggressive men. In the case of open units, staff must be available and out there with the patients to provide therapeutic interactions and also frequent assessments. In this era of the electronic health record, it is common to see people sitting in unit offices charting on computers all day long. That is not an approach that optimizes the therapeutic environment. The units themselves have to be staffed with people who are comfortable dealing with aggression and who know how to address it. The environment has to be secured against contraband weapons and drugs and all material coming into the unit needs to be searched. Metal detectors are also employed to detect any weapons coming into the unit. I have also witnessed incidents where visitors have become physically aggressive and threatening to staff. One of the logical flaws of gun advocates is that anyone who is licensed to carry a firearm always acts in a rational manner. You don't have to be a psychiatrist to see that as an unrealistic statement.
The real problem in visitors carrying weapons into a psychiatric facility is the potential adverse impact on individual patients who are being treated there. To cite a few examples:
1. Patients with a history of trauma and in some cases post traumatic stress disorder. These patients are hypervigilant and scanning the environment for the slightest hint of danger. What would appear more dangerous than a person walking in with a gun?
2. Patients who constantly expect to be harmed or killed - paranoid patients. During inpatient work it is common to have many people with this problem.
3. Suicidal patients who may have those thoughts under fairly good control until these see a highly lethal method within arms reach.
4. Aggressive patients who may have been involved with weapons prior to admission and immediately gravitate towards anyone carrying a weapon.
There are more examples, but in our society guns are powerful symbols. Any powerful symbols tend to be amplified in many predictable and unpredictable directions by psychopathology. The other unappreciated fact is that there is a psychological environment in any hospital setting. That environment is the conscious and unconscious product of every staff person, patient and visitor in that facility. Unless that environment is actively managed for safety and affiliative rather than confrontive interpersonal communications there is the potential for major problems. Carrying firearms into a psychiatric facility is more than a bad idea. It is an inexcusable use of a psychiatric facility for political purposes at the cost of a therapeutic environment.
In order to get more details about this legislation and the positions of Texas psychiatric organizations I sent an e-mail to the Texas Psychiatric Federation - a website that lists Texas Society of Psychiatric Physicians, the Texas Academy of Psychiatry, and the Texas Society of Child and Adolescent Psychiatry as the major professional organizations in the state. I am interested in getting feedback on the positions that these organizations are taking as well as the position of the American Psychiatric Association. I delayed posting this for a few days but so far have not received a reply. I will post information in the comments section as it becomes available.
Every psychiatric professional organization and every psychiatrist should know what is wrong with this picture and demand safe and therapeutic hospital environments for our patients.
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George Dawson, MD, DFAPA
References:
Rick Jervis. Texas allows guns into state mental health hospitals. USA Today August 8, 2016.
http://www.usatoday.com/story/news/2016/01/08/texas-open-carry-psychiatric-hospital/78522138/
Attributions:
The graphic at the top is downloaded from Shutterstock via their Standard License Agreement and is copyrighted by Bob Orsillo.
I read somewhere that men and women were housed together on inpatient units because they found it calmed the men. Is that accurate?
ReplyDeleteAnd why would that be a reason to put woman at a greater risk of violence?
Now that psychiatrists no longer run psychiatric hospitals nothing would surprise me. Any number of new age theories can be applied if you don't know what you are doing. Populations need to be segregated based on various needs. From what I have seen this would not work. There is also a concern about how to prevent sexual contact in populations of vulnerable adults.
DeleteBack in the 1990s the 16 bed inpatient unit in the hospital where I worked was mixed gender. I don't know if it still is.
ReplyDeleteI was able to find a reference to the belief that keeping genders together reduced male violence and, not surprisingly, it also supports your take on the practice:
http://psychcentral.com/blog/archives/2010/05/10/when-violence-strikes-on-a-psychiatric-ward/
I think it also illustrates the problem when administrators and boards manage patient flow and the milieu on inpatient units - rather than psychiatrists.
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