Billboard - Stigma or Not?

I don't know how I missed the controversy but the APA has vigorously criticized a billboard that sends a message about inadequate access to mental health services and inadequate gun control.  I found out about it only through the APA listserv yesterday.  The Psychiatric News alert can be viewed here.  The billboard can be seen on major news services like NBC here.   If anyone can spare a photo of this billboard please e-mail to me and I will post it in the body of this essay.  The message basically states "Over 40 million Americans with mental illness - some can access care - all can access guns."  It is signed by Kenneth Cole.  He has a history of activist billboards and Twitter posts and is no stranger to controversy.  He has also discussed raising his brand's profile through the social responsibility messages.  In this case some APA members were outraged at what they perceived to be a stigmatizing message.

My perspective is that the message on the billboard is accurate. There is nothing to be gained by suggesting that Mr. Cole is trying to state that most people with mental illness are dangerous.  But there is the issue of whether a professional organization should be commenting on what they perceive as a controversial billboard in the first place, especially when it may be used to promote a brand name.  In this era of social media and the current trend for public shaming, I would suggest that scoring points in that landscape is the last thing any professional organization should be doing.

The fact is that most acute care psychiatrists are making these kinds of assessments every day in the United States and multiple times a day.  The vast majority of people designated to have a mental illness on this billboard do not need to see psychiatrists.  Acknowledging the fact that psychiatrists are actively engaged in violence prevention and that a small but significant number of people with mental illness are violent and aggressive and that it is a treatable problem is a very important message.  The potential benefits include:

1. Less stigma for people who are violent and aggressive as a result of severe mental illness.  The current bias is to see this behavior was willful and punish them based on a moralistic approach to mental illness.  That is until the violent and aggressive person is a family member trying to harm other family members.  At that point, there is no myth of mental illness and all of the talk about how the mentally ill are not aggressive is meaningless.

2. Clearly define the problem and develop centers of excellence for treating this problem.  In every metro area in the U.S. there are a handful of acute care psychiatric units and even fewer who accept violent and aggressive patients.  All of the violent and aggressive patients are typically brought to one or two hospitals that are set up to address the problem.  Those hospitals have protocols in place to treat the problem and many of them do a lot of civil commitments.  There is no funding source that is adequate to provide the level of treatment for these patients who must be hospitalized until they are no longer dangerous.  They also require more intensive staffing patterns by staff who must have a much higher level of training than in less intensive situations.

3. A denial of the potential for violence and aggression is inconsistent with the recently released Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition.  That document has explicit commentary about the psychiatrist’s role in addressing aggression.  There are 41 references to aggression in the body of the paper including 13 bullet points on the Assessment of Risk For Aggressive Behavior (p 23).  There are thirteen references to firearms.

In my opinion, the assessment of violence and aggression that is typically done in crisis situations by psychiatrists is more extensive than what is captured in the guideline. As an example there is no discussion of transference or countertransference issues and how they affect the treatment team and their approach to the safe treatment of violent and aggressive patients.

4. A more clearly defined role among advocacy organizations is a better role for professionals. The political use of the term “stigma” is at times all encompassing and it obscures the real source of the problem. For example, stigma is not the reason why there are no services available for psychiatric care.  Managed care companies and the governments that subsidize them and sanctify their business tactics are the reason there are no services.  The APA has been talking about stigma for years and it has done absolutely nothing to increase services or stop the rationing.  The highly acclaimed parity legislation initiated by Senators Paul Wellstone and Pete Domenici has done nothing to break the chokehold on mental health by businesses and governments.  There is new legislation in the works to “enhance” the original parity legislation because it has no teeth and has not made a difference. Businesses do what they want with the blessing of state and federal governments.

5. In some cases advocacy organizations are at odds with clinical psychiatrists who are treating patients with severe mental illness and aggression.  One of the positions taken by at least one of these organizations is that psychiatrists could be easily replaced by “prescribers” in state hospitals where aggressive patients are sent.  The government in that case took the position that an administrator with no clinical experience could come into a state hospital setting and develop a program to treat patients with mental illness and violence and aggression.  That plan failed.

These are a few of the problems associated with denying the correlation between severe mental illness and violence and aggression in a subset of patients with severe mental illness. The reality is that there are thousands of psychiatrists that face these problems every day. Their goal is to keep people safe and prevent violence. Acknowledging what they do on a daily basis, supporting that work and the importance of that work to patients, families and the community is a step in the right direction.

Suggesting that it is too stigmatizing to discuss that issue is not a step in the right direction.




George Dawson, MD, DFAPA



Supplementary 1:    I contacted Kenneth Cole (the company) through the web site and asked them to send me an image of their billboard for use in this post.  I included a link to the post so the specifics could be read as well as the entire blog.  I was advised that although they appreciate my interest, the image was proprietary and therefore they could not send it to me.  I don't know if they are claiming that about every image or just the one I wanted them to send me.  It made me wonder if they are aware of how widespread the image is used on the Internet.

Supplementary 2:   I was graciously sent a photo of this billboard by a resident New Yorker.  I contacted Kenneth Cole again and was told again that I could not even use an independent photograph of their billboard for this post.  I really doubt that any place else displaying these billboard photos has gotten permission from them, but I am just a guy writing a blog and can't afford to get into it with them.  So there you have it.  Go to any one of the other hundreds of places on the Internet that have posted this picture to view it.

    

Death Cults

That may seem like an odd topic for a psychiatry blog but I did not know where to put this.  Earlier this week my wife and I decided to stop watching a popular television show called The Following.  It is basically a fictional show about a death cult that involves a charismatic psychopath who engages other psychopaths to do mass killing.  They typically use knives as murder weapons and kill large numbers of innocent people at public gatherings like book signings in book stores.  In one episode last year, the main psychopath in the show happened across the camp of another death cult run by a different psychopath and it was the expected lethal battle for leadership.  The dramatic tension is created by a group of FBI agents trying to catch and stop the psychopaths and the personal stories in that group.  In the opening show this year, there was a murder scene that was explained to the audience and then implicitly done that was so sadistic and so sick that we decided to shut off the show and never watch it again.

Violence and aggression are always in the background in America.  We take violence and aggression for granted and it seems surprising when they are excluded from entertainment.  What no car chases or shootings?  And it has been there a long time.  I can remember being in East Africa in the 1970s and at that time many of the Africans that I met, had the idea that most Americans carried guns.  That conclusion was from watching American films.  There has always been the debate about whether or not the display of all of this violence affects people.  Like practically all research of this type, I would expect the results to reflect the biases of the researchers.  Typical research would look at a large group  exposed and not exposed to violence in the media and the results are mixed.  Mixed results lead to the status quo, but the status quo has gradually gotten worse.  Television shows commonly have sadistic serial killers as their plot line and in one case a serial killer is the main character and hero.  

According to a 2012 report by the Media Violence Commission (1) major medical (including the American Psychiatric Association) and the major psychological organization in this country support the argument that there is a casual connection between media violence and aggressive behavior.  This report also looks at the biases that may be in place that might obscure that connection.  The authors mentioned the belief that the effects must be immediate and severe is a common bias.  In other words, I see a violent movie and perpetrate a violent act within the next day or two.  Instead over time, exposure may decrease prosocial behaviors.  This report briefly summarizes the literature on possible psychological mechanisms that occur with exposure to violence but the most important  conclusion is:

"One conclusion appears clear-extreme conclusions are to be avoided. Not every viewer or player will be affected noticeably, but from understanding the psychological processes involved, we know that every viewer or player is affected in some way."

Many clinical psychiatrists have talked with people who have perpetrated violence based on some act that was portrayed in the media.  These stories are also described in the media with some regularity.  I think that if there are any factors containing a media effect it is the moral development of most people and that fact that a lot of the violence is hypothetical and it could not be enacted without considerable resources.  Factors that may facilitate violence after exposure would include a developmentally immature brain or a brain that would be more susceptible to the priming effects of violence.  That would include various forms of severe mental illnesses or personality effects like psychopathy or antisocial personality disorder.  In many cases the perpetrators of violence has no idea about how devastating injuries can occur from fictional portrayals where people get up after being hit over the head with a pipe.  They don't realize that in many cases that results in a fatal or disabling brain injury.

The overriding dimension affecting violence that needs to be addressed is at the cultural level.  A critical recent development is the resurgence of the death cult.  The concept of death cult is poorly defined at this time and as far as I know there are no definitive scholars.  They seem to come in two forms.  The first requirement is a cult or an organization with a charismatic leader and followers who are willing to uncritically follow the edicts of the leader.  There have been various studies of the dynamics of these groups and who might be susceptible to becoming a cult member.  Jerrold Post, MD has analyzed the dynamics of charismatic leaders and describes them as "mirror hungry" personalities that require constant admiration, convey a sense of omnipotence and grandeur,  have the appearance of certainty, and rely heavily on splitting as an adaptive psychological defense (2).   Death cults seem to come down to 2 varieties - those predisposed to mass suicide and those that are predisposed to homicide and mass homicide or in some cases genocide.  For the purposes of this post, I am focused on the latter, because they seem to pose the most immediate danger to the most people.

Prototypical homicide focused cults or movements in my lifetime have included the Nazis and Pol Pot.  The concept of "charismatic leader" can probably extend to larger groups of extremists that have been described as being responsible for genocides (3).  Over the past 30 years, we have seen many of these cults or movements commit homicide to various degrees often with loose religious rationalizations.  The killings have become increasingly vicious and sadistic.  The killings have reached a level of intensity that all of the religious justifications no longer seem to apply.  The international solution has been to mobilize against these groups and in some cases, explicitly threaten to kill them.  The media is always complicit with death cult propaganda and the resulting desensitization may have been one of the factors in the escalation.  This is an interesting parallel with television entertainment that seems to be in the same cycle of escalating to the most horrifically sadistic and brutal types of killing and torture.

What is missing in all of this mass exposure to violence and killing is an explanation of the driving forces and a plan for change at a cultural level.  There is a current and shocking increase in antisemitism spreading across Europe, to the point that one author has suggested that it may be time for the Jews to leave Europe (4).  There don't seem to be any pacifists any more.  There is no peace movement like there was in the 1970s.   I have not seen any explanations for this primitive behavior and why it occurs even though many explanations have been around for years.  Here is one from Lifton that has been available since 1986 and it is accessible to any psychiatrist trained in psychodynamics or any good student of English literature:

"Fascist ideology can have particular appeal for the survivor self fighting off disintegration because it holds out, at all levels, a promise of unity, oneness, fusion.  It deals with death anxiety, moreover by glorifying death, even worshiping it.  While one's own death as a warrior is idealized, the self mostly escapes death - achieves the death of death - by killing others.  There can readily follow a vicious circle in which one kills, needs to go on killing to maintain one's cure, and seeks a continuous process of murderous, deathless, therapeutic survival.  One can then reach the state of requiring a sense of perpetual survival through the killing of others in order to re-experience endlessly what Elias Canetti has called the "moment of power" - that is the moment of cure."  p. 499.

Lifton knows full well that the fascist thought process that he describes is not a diagnosis,  but it is the way that large groups of people can think.  It has been present since the time of ancient man.  You can find theories about how it is "hardwired" into the human brain with suggestions that it is adaptive.  The only real way we can combat it is through educating people about what is really going on, improving critical thinking and changing popular culture.  Teach them how to recognize biases and overcome them.  A basic skill would seem to be able to recognize a death cult and realize why participation may not be in your best interest.  It goes without saying that it could not be in the best interest of civilized society, but the philosophy behind that probably needs teaching.

When I turned off my TV set the other day, I was not seeing it as a protest.  But if media producers realize that abhorrent violent content is less interesting that may be an important cultural change.      


George Dawson, MD, DFAPA




References:


1:  Media Violence Commission, International Society for Research on Aggression(ISRA). Report of the Media Violence Commission. Aggress Behav. 2012 Sep-Oct;38(5):335-41. doi: 10.1002/ab.21443. Epub 2012 Aug 10. Review. PubMed PMID: 22886500 (full text available online).

2:  Jerrold Post, MD.  Personality and Political Behavior.  Door County Summer Institute July 21-25, 2003.

3:  Alan J. Kuperman.  The Limits of Humanitarian Intervention - Genocide in Rwanda.  Brooking Institution Press.  Washington, DC (2001) p. 12.

4:  Jeffrey Goldberg.  Is It Time for the Jews to Leave Europe?  The Atlantic.  April 2015.

5:  Robert Jay Lifton.  The Nazi Doctors.  Basic Books, New York (1986) p. 499.




Supplementary 1:    I would not encourage anyone to watch the television program in question that I mention in paragraph 1.  I have seen plenty of media violence, but consider this depiction to be the worst.

More On Violence And Aggression In Minnesota Hospitals

There was a recent incident (see link within that article) that occurred in a Minnesota hospital a few weeks ago that resulted in serious injuries to nursing staff.  There are various sites on the Internet where you can view the videotapes that were obtained from the hospital's security cameras.   It shows an out of control man chasing and striking nursing staff with a metal bar or pipe, in some cases repeatedly.  The patient in this case was eventually apprehended outside of the hospital and died suddenly after he was tasered, taken to the ground, and handcuffed.   Preliminary information suggested that the patient involved in this situation was probably experiencing an acute change in his conscious state because it was a total departure from his personality and he had no previous episodes of aggression or violence.  Nursing staff sustained serious injuries including a pneumothorax.  Autopsy results have not been released at this time.

Many people were shocked by this activity and yet is is a fairly common occurrence.  People may expect this kind of agitated and aggressive behavior to occur only on psychiatric units, but the reality there is that is happens only on a few psychiatric units.  Most psychiatric units are managed to limit the admission of patients with a high potential for violence.  It happens on medical-surgical units for a number of reasons and the effects are more dangerous at times because of the availability of objects that can be used as weapons.  I have seen stands used for hanging intravenous solutions being swung in a wide circle through an intensive care unit.  These stands have heavy bases that can inflict serious injuries and destroy a lot of equipment in an ICU.  There are many possible reasons for this kind of aggressive behavior ranging from delirium and psychosis on one end of the spectrum to antisocial behavior and wanting to intimidate medical staff on the other.  Although it seems incongruent with a controlled hospital environment, many families have an experience with a family member who suddenly loses control.  The proscription on aggression and violence and the moral interpretation of this behavior often makes it difficult for families to comprehend what is happening.  Families and medical professionals alike often lack the vocabulary for describing this behavior and can just lump it together as "bad" behavior.

I saw the preliminary description of this incident and the video clips and decided not to comment on it until after the results of the autopsy and investigation were known.  The idea that  this problem would be approached by making this behavior illegal made me change my mind for a couple of reasons.  First, there is a very high probability that this behavior was precipitated by a medical problem that led to a change in consciousness to the point that this individual had no control over his behavior.  Anyone who has been delirious has experienced this at one point or another.  In my own family one of the male relatives who was a well driller was apparently "blown up" in a well one day and the resulting brain injury led to permanent and extreme changes in his behavior.  From that day on he was extremely aggressive and the aggression was directed toward property.  He continuously overturned furniture and smashed dishes until the entire house was trashed.  In those days before any care or containment was available, the expectation was that the family would care for him and they did until he died.  The home environment was constantly disrupted by rage attacks until that day.  In my capacity as an inpatient psychiatrist, I would routinely see people brought to the hospital after they suddenly became aggressive at home.  When their relatives arrived they were always shocked to find that the patient had been admitted to a psychiatric unit.

My second reason for concern is the involvement of politicians in what is a misunderstood medical problem.   An acute medical problem causing aggressive behavior in not a criminal act - it is a medical problem.  Attempting to incarcerate or fine a person for aggression that occurs in that circumstance does not make any sense at all.  It may be a way to secure political capital from a special interest groups, but criminalizing a medical problem is not a reasonable approach.  Even suggesting that this is something that should be debated in a court of law is questionable.  I base that on the known track record of the not-guilty-by-reason-of-mental-illness defense.  It is widely known that there is a low probability of that defense succeeding.  It is also widely known that people who have committed criminal acts and who clearly have severe mental illness  are typically convicted.  All it usually takes is a expert testimony suggesting that despite any mental illness diagnosis, the defendant appeared to be taking planned steps to achieve a goal.  In the case of aggression those steps would involve assaultive behavior and destruction of property rather than random activity.  I can say that in every case of aggressive behavior that I have witnessed in a hospital, even in cases where the patient had no subsequent recall of the incident that their behavior appeared to be planned and the assaults were directed.

On the non-medical side of the spectrum, there are people whose conscious state is not altered at all and they have directed violence as part of their personality structure.  Threatening and assaulting people are a way of life.  They frequently have criminal backgrounds or an arrest record.  They often give a history of fighting and may have harmed someone when they were defenseless or felt no remorse if their aggressive behavior resulted in injury or disability.  In my experience the majority of these persons can control themselves in medical settings with a few exceptions.  Any drug or alcohol intoxication state makes them more unpredictable.  Seeking prescriptions for controlled substances like opiates or stimulants can also create confrontations if they don't get the prescription that they are seeking.  There may be a question about whether any special legislature penalizing what is essentially criminal assaultive behavior would be useful.  My guess is that it would not for the same reason that civil commitments fail to work - the laws are not utilized.  Hospital administrators and courts tend to ignore aggression toward medical and nursing staff from patients who are willfully directing violence toward them as a product of their usual conscious state.  Administrators always explained it to me as an occupational hazard, especially on the part of the nursing staff.  That casual attitude often leads to inadequate safeguards at every step.  There should be a zero tolerance attitude for personality disordered violence and that should include prosecutions for assault.

The key to protecting medical and surgical staff and their patients from aggression associated with acute changes in consciousness is to have a heightened level of awareness.   The patient's history prior to admission is critical.  Prompt recognition of delirium from many causes and acute drug and alcohol intoxication and withdrawal states is necessary.  Adequate staffing is critical.  There needs to be a definite team approach, all of the staff on the unit need to be aware of the potential for violence, and the priority needs to be on protecting the nursing staff delivering direct care to the patient.  Medical staff and nursing have to be on the same page and there can be no factors present that lead to split treatment.  Enlightened administrators may be helpful in preventing that dynamic, but in my experience I have not found any.

One of the common problems is that staffing on some of these cases involves 1:1 observation preferably by a trained psychiatric technician or nursing assistant who knows how to help patients de-escalate.   Just having a reassuring person in the room can often have the same effect.  There are protocols that address the physical environment to reduce the likelihood of post operative delirium.  Where necessary it is useful to have experienced staff treat acute agitation in hospital settings with medications.  Some large hospitals have psychiatric consultation 24/7 to address the problem and in some cases where the patient is medically stable transfer them to a more secure psychiatric environment for assessment and treatment.  Medical and nursing staff need to be in close contact 24/7 in order to make rapid adjustments in the treatment plan.

Making the aggressive behavior associated with explainable medical problems a crime is the wrong approach.

When I see legislators talking about what medical professionals do or do not know about containing violence and aggression my typical response is to cringe.  I put it on the long list of all of the other things that legislators think they needed to train physicians in - like how to prescribe opiates (in the year 2000) and then how not to prescribe too many opiates (in the year 2010).  There are plenty of people who come out of training who known how to assess and treat aggression.

They are called psychiatrists and psychiatric nurses.




George Dawson, MD, DFAPA            

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression

I was shocked to see this article posted on a CBS web site.  I was shocked because I was completely unaware  that such a law existed.  I was shocked because Minnesota has fairly well documented problems in their state hospital system.  The state security hospital has had numerous problems with containing violence and aggression and there is no evidence that situation has been resolved.  There are very few specialized units in hospitals in the state that could potentially deal with the problems of violence and aggressive patients.  There has been no effort to modify the limited infrastructure in the state that has been the result of managed care-like rationing over the past 20 years.

The story is a lot more involved than suggested by the news article.  When I read it I contacted my state legislators and asked for clarification primarily by pointing me to where the "12 hour rule" existed in the State Statutes.  The Minnesota State Statutes are generally easy to search but I could not find it.  My state Senator got back to me and suggested that this is the rule in 253B.10 PROCEDURES UPON COMMITMENT.  Chapter 253 is the civil commitment statute and reading through this chapter suggests that transfers from jail to state mental hospitals have to be adjudicated as mentally ill by civil commitment.  Other pathways include being found not guilty by reason of mental illness, and for examination or determination of competency to proceed to trial.  Apart from the time constraint, that part of the statute does not materially alter patient flow to state hospitals.  The statute gets more interesting with the following subdivision:

Subd. 4. Private treatment.

Patients or other responsible persons are required to pay the necessary charges for patients committed or transferred to private treatment facilities. Private treatment facilities may not refuse to accept a committed person solely based on the person's court-ordered status. Insurers must provide treatment and services as ordered by the court under section 253B.045, subdivision 6, or as required under chapter 62M. 

Private facilities refuse to accept court ordered and committed patients all of the time just based on the fact that severe mental illness cannot be treated on an 8 day DRG payment that in reality is treated like a 4 or 5 day length of stay.

The article itself focuses on Anoka Metro Regional Treatment Center.  That is a state operated psychiatric facility just north of the Minneapolis-St. Paul area.  If the intent of the legislature is to alleviate crowding in jails, the writing of a statute will not do that.  If I had to estimate, the majority of inmates in county jails with significant mental illness and addiction problems are not committed and do not meet the forensic criteria suggested in the statute.  The article also illustrates the ambivalence that the state government has toward state run hospitals.  Not too long ago, the legislature wanted to close this hospital down.  Many states have adopted the managed care rationing model to mental illness.  They reasoned that the best way to "save" money is to close down state-run hospitals and clinics.  I have no doubt that the state would close it down if possible but it occupies too central a role in the civil commitment process.  There is instead a detailed political process to manage the hospital (see first reference).  That document is current, 114 pages long with 41 references to "jail" and 37 references to "aggression".  It acknowledges the role of the state in treating aggressive patients with mental illnesses. 

I have no way of knowing if any of the patients mentioned in this article requested transfer to a private hospital.  I would consider any hospital in the state that is outside of the state hospital system to be a private hospital because at this point they are all parts of private health care systems.  Only a fraction of community hospitals in the state have psychiatric units and a smaller portion of those are equipped to treat violent or aggressive patients.

I have tried to elaborate on this blog the type of structure necessary to treat people who are violent and aggressive as a result of mental illness. Any time that correctional populations are considered, the problem is more complicated than mental illness or not.  There are many individuals with sociopathy or personalities that are anti-authoritarian and with a tendency to criminal behavior.  At the extreme end a variant of psychopathy has been described where criminal tendencies, combined with a lack of empathy leads to an individual who is potentially more dangerous.  Those individuals often have a history of repeated violence against others and a pattern of planned violence as way of life.  The associated issues are that patients who are predominately personality disordered criminals are better taken care of within the correctional system.  Patients with primary mental illness who are incarcerated for non-violent crimes or violent crimes that occur only an episode of discrete mental illness are probably better treated in a mental health setting - especially if that is a continuation of their ongoing care.  Those statements are generally true because the personality disordered mentally ill will demonstrate a pattern of threatening other patients and staff with physical violence.  They may also exploit more vulnerable patients and try to intimidate them into giving them money, information, or personal favors that they can use to their advantage.  Those behaviors are goal driven, reinforced by a life of crime, and not likely to change as a result of any psychiatric intervention.

The article states that 146 inmates have been transferred from Minnesota jails to state hospitals since July 2013.  There is an eye witness account of what has occurred and a description of some of the injuries to staff including facial fractures and a torn shoulder tendon as the direct result of assaults on staff.  There is also the following statement from the affected staff person:

 And though she agrees there are other factors behind the rise in workplace injuries — a hesitance to use force against potentially abusive patients chief among them — she said she and her co-workers believe the 48-hour rule is largely responsible.

The issue of the use of physical force in psychiatric hospitals was also the primary cause of the upheaval in the previously cited problems at the Minnesota Security Hospital. A change in administration occurred to address the issue of patient injuries due to physical interventions. According to news reports that and the associated administrative measures were associated with an increase in staff injuries. We are left with the impression that there have been no effective interventions to prevent patient and staff injuries in state hospitals and the problem of aggression in these facilities has been poorly addressed. Organized psychiatry in the state has been silent on these issues.

The bottom line in this article is that it illustrates that Minnesota politicians and bureaucrats have no understanding of what is required to treat people with mental illness and aggressive behavior.  Their misunderstanding is significant and it occurs at multiple levels.  First, they have no understanding that the current system of mental health care is based on a system of rationing designed to provide minimal to no mental health care.  That all starts with hospital systems that have been rationed to the point that there are often no detectable changes in the mental health of the people admitted compared with the people discharged.  Psychiatric care in rationed hospitals is designed to limit treatment to a brief period or reimbursement.  Second, they have a track record of using mental health jargon to come up with their own diagnostic category of "sexual psychopaths" that can be used for indefinite confinement of sex offenders.  This categorization allows for diversion away from a correctional system that is apparently unable to confine sex offenders to the satisfaction of politicians and their constituents.  Third, the state managed security hospital has had a number of problems in the past few years including the mass resignation of psychiatry staff and an increasing number of injuries to hospital staff.  Fourth, Deputy Human Services Commissioner Anne Barry is quoted in the article. She was also quoted in previous articles about the Security Hospital. She attributes the problem to unintended consequences. To me that suggests a complete misunderstanding of psychiatric services in the state of Minnesota. Any psychiatrist in this state, especially if they work on an inpatient unit would be able to predict this problem. Commissioner Barry has also been quoted in the articles about the Security Hospital (see below)  Fifth, the direct quote by State Sen. Kathy Sheran also illustrates a misunderstanding of the problem. The idea that state hospitals are holding large numbers of people who don't need to be there is longstanding political rhetoric. In the absence of environments that can assist severely disabled individuals the default environments are hospitals. It is glib to say that people should no longer be a hospital when they have no safe place to live outside the of the hospital. As a reviewer of hospital admissions and lengths of stay, the presence of acute symptoms is typically used to mark who should be in a hospital. Chronic severe psychiatric disorders have a number of problems with cognition and functional capacity that lead to an inability to care for self independently of acute symptoms.  The associated political problem is a lack of funding for community based programs to resolve the problem.  As I have previously posted in many cases these community based programs that are inadequately equipped to contain aggression place both patients and staff at higher risk.

I qualify this post with the same qualifications I have put on previous posts on the topic on state run facilities.  The only source of information I have on this issue has been the press and legislative reports on mental health services in correctional facilities and at Anoka.  Media reporting of psychiatric issues and services leaves a lot to be desired and typically vacillates between blaming psychiatrists for all of the problems and tragic cases that result from a lack of services.  The only corroboration in this article seems to be the reaction of state politicians to it.  We have seen similar reactions to these issues in the press.  Unless there are some outright denials about the scope of the problem, something needs to be done.  The last thing we need is a state run Task Force or Commission investigating  itself.  The second to last thing we need is consultants hired by the state to write another report.  At this point, I don't even think that a review of the incidents is possible.

Any hospital in the state should be required to prospectively flag records based on violence, aggression and whether they were transferred from the correctional system.  All of the staff in those cases should make a recording of their perceptions of the antecedents, intervention and why it failed or succeeded, and the outcome.  Those cases should be reviewed on a weekly or monthly basis by psychiatrists with experience in treating severe mental illnesses and aggression.  That panel of psychiatrists should be carefully screened for conflict of interests, especially any financial conflicts of interest with the State or any other entities responsible for providing the treatment in question.

It is time to solve this problem.  Having the problems analyzed time after time by the same people who do not understand the problem and who can not possibly come up with a solution has not worked in the past 5 years and it will not work in the future.  Instead we have a state official charged with solving the problem saying that fewer psychiatrists makes sense and psychiatric expertise at the systems level is not needed as the system continues to collapse.  The system of state hospital care for patients with serious mental illnesses and aggression may not be salvageable at this point without realistic backing by the state.

A key part of the miscalculation appears to be casting psychiatrists in the role of generic technicians.  Of course these technicians would not have any understanding of patient centered care or a therapeutic alliance despite the fact that they have been writing about it for over a 50 years.  This accomplishes two goals at least at the rhetorical level.  It makes it seem like untrained administrators can address systemic issues of violence and aggression.  It also makes it seem like the only thing psychiatrists can do it prescribe medications - often to "stable" people.  Far too many errors have been made and public statements on the issues are consistent with a lack of appreciation of the problem and a complete lack of appreciation that psychiatrists are the only people professionally trained to provide this level of care.  This is by no means only limited to state systems.  These attitudes are prevalent in any hospital or clinic that is under the direction of a managed care system.

Will the problem of aggression in people with severe mental illness be addressed by arbitrary rules on patient flow and a treatment program that is flowing down from politicians and bureaucrats?  Will the problem be solved by a consensus of stakeholders?  Will the problem be addressed by new age jargon and philosophy?

I don't think so.


George Dawson, MD, DFAPA

Refs:

Minnesota Department of Human Services - Direct Care and Treatment. Plan for the Anoka Metro Regional Treatment Center. Direct Care and Treatment and Chemical and Mental Health Services Administrations. February 18, 2014

From the above document:  "Jails also count on AMRTC to take people whose criminal behavior is determined to be the result of mental illness (a new law requires that AMRTC accept referrals from jails within 48 hours of referral). Because of insufficient capacity in the service system, there are lengthy waiting lists for AMRTC beds"  (p 61).

Supplementary 1:  A previous quote from Commissioner Barry: "DHS officials say the facility no longer needs as many psychiatrists because many of the patients are stable and only require psychiatric visits once every three months. In addition, Barry said, the importance of psychiatrists at the facility has lessened over the years. Psychiatrists are just one part of the treatment team, she said. Nurses and psychologists also play an important role in patient care, and in many cases, advanced practice nurses can handle many of the tasks that used to be the responsibility of the psychiatrists, she said."

Supplementary 2:  I was unable to find any statute that described this 48 hr transfer rule.  I have asked my state representatives for assistance since it may not be a statute.  Corrected as of 12/9/2014 with the statute posted above.

Supplementary 3:  If you currently work in a non-state funded psychiatric unit and have received these transfers from correctional facilities please post your experience in the comments section below.  Feel free to post them anonymously and in a way that does not indirectly identify you or the facility that you work at.

Why Would A Psychiatrist Carry A Gun?

I thought I could resist commenting on this issue, but after seeing what the press did with this issue today - somebody needs to set things right.  What may be going through a psychiatrist's mind as they think about arming themselves?  I don't need to speculate about another psychiatrist.  As I recently posted, I have had to make the decision and in talking it over with colleagues many of them had to make similar decisions.  It is definitely not a linear process.  Here are some of the elements:

1.  Contact with aggressive and violent patients who have severe mental illnesses:  In another recent post - the most familiar scenario is the person with paranoia or a severe personality disorder and who uses the psychological defense of  projection or projective identification.  In the popular vernacular a person who tends to blame other people for their problems, even when there is no realistic connection.  That can happen to psychiatrists because of the unique a aspects of the relationship and nature of treatment, but it can also happen to other physicians, therapists, and counselors.   In many  cases the blame is projected onto anyone who works for the organization or clinic and that puts everyone in danger - including the clerical staff.

2.  A significant substance use disorder:  The usual scenario is the severe psychiatric disorder, aggressive behavior and a substance use problem.  Most intoxicants are disinhibiting and they have the potential for activation, increased paranoia, and increased psychosis with impaired judgment.  They can also lead to aggressive or suicidal behavior that occurs during blackouts.  That not only increases the likelihood of action on a threat but makes any contact with patients in this context very problematic.  That includes crisis intervention centers, emergency departments,  acute inpatient psychiatric facilities, and detox facilities.  It is crucial that all of these settings have adequate staffing and crisis plans to contain both any  aggression that occurs and ways to limit access to people with weapons or people who are out of control.  In some cases patients with acute intoxication need to be rapidly sedated to prevent self injury or injury to staff.

3.  A specific threat against self or family:  Any threat needs to be taken seriously and this is also a training point.  Every mental health professional needs to learn how to address this issue and the first step is to make sure that everyone in the workplace is aware of the threat.  A threat assessment needs to be done and matched with the appropriate plan.  Those plans could range from an immediate call to the police, emergency hospitalization,  civil commitment, and interventions about how the clinic or hospital will interact with that person in the future.

4.  Police involvement:  This is not a debate about gun rights.  Nobody tells you in medical school that homicidal patients are an occupational hazard.  Nobody tells you that if somebody threatens to kill you - you may be on your own.  When you hear about some of these scenarios on television and in the movies one of the themes typically is:  "Well these are just threats.  He/she hasn't actually done anything yet so we can't do anything."  That was a very common attitude from law enforcement 20 years ago.  

Attitude problems can also exist at the court level.  I have testified in hearing about threats where it was suggested that this was an occupational hazard for psychiatrists and therefore less relevant as evidence of criteria for commitment.  Nursing staff are also subjected to these illogical attitudes.  Assaults on nurses are commonly viewed as an occupational hazard and the administrative response is generally that the responsible patient is never prosecuted.  In this era where civil commitment is often watered down to the point that it is completely ineffective, court ordered treatment from a criminal rather than a civil court may be the only available treatment.

A lot of laws have changed in the past two decades and the police should be able to do a lot more at this point.  In recent cases of telephone threats, even very indirect telephone threats, the police will often make a visit to the person making those statements and explain new laws about terroristic threats.  Any mental health professional should not accept the idea that something beyond a threat needs to happen before law enforcement can get involved.  The only action necessary is a threat.  What the police actually do is frequently a determining factor in whether a firearm is acquired.

5.  A secure treatment environment:  There are many aspects to this dimension including access to the physical environment, staffing, and the security arrangements.  Are there security cameras?  Are they actually monitored by security staff.  Is physical access to the environment limited to a few staff?  Most inpatient psychiatric units are locked.  I have been grateful many times that the locked door was more useful for keeping people out rather than preventing patients from leaving.

6.  An awareness that psychiatrists and other staff are killed by aggressive patients:  This happens frequently and it has been going on for a long time.  It tends not to make the papers anymore.  Here is an old New York Times article that was uncharacteristically blunt about the problem.   It described a full spectrum of homicidal aggression toward psychiatrists back in 1983.  That was the same year that I became an intern and I don't remember ever seeing this article.

7.  A functional administration:  Lack of an administrative support that prioritizes the treatment of violence and aggression and an associated systems approach to violence prevention is critical.  The appearance that a single psychiatrist is in a confrontation with a potentially violent and aggressive perpetrator needs to be avoided at all costs.  Staff splitting that encourages patients to act on aggressive wishes toward a staff member need to be avoided at all costs.  This may sound like common sense function, but in my 30 years as a psychiatrist, I have never seen a situation like this handled appropriately by administrators.  In fact, I have seen just the opposite when administrators dislike a staff person and suddenly there are rapid succession of administrative, staff, and patient problems focused on that person.    

It is very likely that the business oriented, "customer friendly" approach to patients that has been promoted by managed care has the potential for making these situations much worse.  It is hard to imagine a worse situation than to find out that a potentially aggressive patient who has threatened you is now being taken seriously by various patient representatives, customer service representatives and ombudsman.  Many of these patients realize that the state medical board is a gold mine in terms of being able to continue the harassment of the object of their aggression.  Multiple complaints against multiple parties can be filed even when it means that egregious threats made by the patient are included in the medical documentation will be sent to the medical board.

8. Dynamic issues:  There are a number of critical issues related to individual and group psychodynamics.  I have heard the term "therapeutic grandiosity" used to describe a situation where a psychiatrist failed to anticipate a dangerous situation and ended up injured or killed.  I think it is far more likely that the psychiatrist involved did not recognize different conscious states of the patient and the fact that one of those conscious states was capable of severe aggression.   Many people seem to be confused about legal definitions or reduced capacity here.  The law believes that a rational act that is internally consistent with a given psychotic state means that the person is responsible for their actions.  Every psychiatrist knows that there are mood disordered and psychotic states that result in decisions that the person would never have made if they did not have a mental illness.  One of those decisions is deciding whether or not to become aggressive toward their psychiatrist.   Making that determination can depend on very subtle findings.   If they are missed and there is an agreement to meet about an issue, especially if it is after hours the clinician may find that they are interacting with an unexpected person.  The structure of a clinic schedule and a crisis plan for that clinic can provide a basic background for not making these mistakes.

On an individual level, it is possible to view a patient's aggression as a personal failing on the part of the psychiatrist.  Many psychiatrists who have been assaulted are full of doubt about what they missed and whether the care being provided was adequate.  It is easy to lose sight of the fact that any physical aggression toward a physician is grossly inappropriate.  In the cases I have been personally aware of most of the psychiatrists were spontaneously assaulted and were not even interacting with the aggressive patient at the time.  In many cases the assaults occurred by patients who did not even know them.

There are also interpersonal dynamics that are disquieting at times.   Other staff speculating on the origins of the assault or threats, acting like the aggressive behavior can be interpreted.  This often occurs with little knowledge of the patient and their unique characteristics.  In some cases assaultive behavior is explained away on psychological grounds and the person who has been assaulted is unsupported  and alienated from the rest of the staff.  In my experience, this is a very dangerous position for the the staff to be in.  In an incredible twist, the aggressor seems to have more support than the victim even when the victim has sustained obvious injuries.   Although it has not been studied, it would not be surprising to find that staff in this position would conclude that they have no support, can expect no help, and need to arm themselves or risk annihilation.

9.  Cultural hate of psychiatrists:  There is no doubt that the haters of psychiatry have some influence here.  It is always easier to perpetrate violence against any minority group that is routinely vilified in the media and seen as a stereotyped monolithic group.  The people involved may have difficulty distinguishing symbolic hate and annihilation from the real thing.

All of these factors come in to play in considering whether or not to arm oneself to ward off a potentially homicidal threat.   From the psychiatrists I have talked with, next decision is the threshold for self defense.  Do you carry a weapon or is the threshold your front door?  Are security cameras and alarm systems enough?  I knew a psychiatrist who carried a rifle with him when he was riding his lawn mower.

The critical factor comes down to the threat assessment and all of the mitigating factors listed above.

For anyone second guessing a psychiatrist in this position, the critical question becomes:  "Where would I allow anyone to kill me?"  Is that thought compelling enough to ignore competing ethical considerations, even though there is nothing in medical ethics about a patient trying to kill their physician?  Is that thought compelling enough to ignore the law in order to protect yourself and your family?  What is your threshold for making those kinds of decisions?

For people interested in stopping this kind of aggression, the points above are all considerations of what can be done to stop it cold - long before there is any gunfire.  At that level of analysis, psychiatrists thinking of carrying guns or walking around with them is really a sign as well as an outcome.  It is a sign that multiple systems in society and medicine are either inconsistent, have failed or been corrupted.  We have these systems in place in some places and they can work.  I have seen every one of them work well at some point and prevent aggression and violence.

Fixing that larger problem should benefit everyone including the involved patients.

George Dawson, MD, DFAPA

The Retirement Party

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.

What Is Really Going On At The Minnesota Security Hospital?

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.