Tuesday, November 18, 2014

The Violent Mentally Ill

There's been lots in the news lately about forensic hospitals and the management of violence by psychiatric patients. Here's a short list:

1. Beyond the Gates of Gomorrah

A new book by Dr. Stephen Seager, a tell-all about his work in a California forensic hospital.

2. Broadmoor

A very rare documentary filmed within the walls of a British forensic hospital. In two parts, all on YouTube:

Ep 1 Ep 2


Joel Hassman, MD said...

I read your Clin Psych Times column, and will honestly and freely admit you lost me as an objective reader when I read "Stephen Stahl" as a contributing member of the guidelines. Once again, psychopharmacology is going to save not only the patient, but society simultaneously. Yeah, right!

You know what, I have been practicing for over 20 years, and I know I am a lot more right than wrong in this premise: anger is a symptom, and you can't medicate it without identifying the cause, and that assumes the cause will respond to medication in the first place. But, where has forensic/correctional psychiatric care wandered aimlessly in the past 15 or more years? Oh yeah, find an Axis 1 label, medicate the hell out of it, and then the disorder is treated. One hopes.

Give. Me. A. Break. But, I will give you this, the end of the column had a wonderful point: "Correctional facilities should be willing to provide the treatment resources needed for mentally ill prisoners high in sociopathy, and hospitals must be equally willing to accept severely ill offenders who cannot be medicated within a jail or prison."

Well , but the end of that sentence should have a disqualifying addendum: "...cannot be medicated within a jail or prison who are not a pervasive, ongoing risk to the rest of the psychiatric patient population on the unit."

Then your column would be salvageable to me at least a bit.

Hey, as I always write, just my opinion, based on some experience having done a bit of correctional, inpatient, and moreso endless CMHC work.

Happy Thanksgiving to you and all who read here.

ClinkShrink said...

I agree completely that violence is a behavior and not necessarily a symptom, which is why I appreciate the California guidelines. The assessment requires you to "look under the hood" about all causes, and the treatment isn't just pharmacologic. They even talk about "treatment" (as opposed to management) of sociopathy.

I'm curious what people think about the Broadmoor videos. How would you manage that guy who can only come out of his room when he's got a six person escort? Or the guy who can't make a fruit salad without struggling with his impulses to stab people?

Happy Thanksgiving to you and yours Joel, and to all our readers.

catlover said...

I am getting kinda down about the usually negative focus on people with mental illness. How about all the folks with mental illness who volunteer for stuff? Who take care of their elderly mother? and so on? I know you guys are writing a book about involuntary commitment and Clink is a forensic psychiatrist, so that's gonna lead to discussions of the negative stuff. But surely there are lots of people with serious mental illness out there who are wonderful, too, and interesting to write about (and not just artists. How many stories are out there about bipolar artists/musicians etc? Gag).

One year, I got a Christmas letter from a mental health drop in center friend who is labeled with schizoaffective disorder, along with some coffee cake mix she made up in little baggies. Oh, there was homemade hot cocoa mix, too, with those cute little marshmallows. She was so grateful just to have a tiny HUD apartment with a working microwave. What a change from the more common brag letters I get!

Sometimes, "the mentally ill" are scary and dangerous. Other times, "the mentally ill" are the most wonderful people you could ever know. Plenty often, the reason they are wonderful is because of the terrible experiences they've had.

Anonymous said...


You are right on target. But sadly, as a six year old stated at a place I worked at several years ago that was totally unrelated to healthcare, sensational headlines sell newspapers.

Sheesh, talking about a mentally ill person who is good to his/her elderly mother and doesn't kill her just doesn't make for an exciting headline.

Of course, blogs like the Shrink Rap and related ones could take the lead in following your suggestion. Instead of analyzing to death why someone like Adam Lanza went on a killing spree, why not highlight a feel good story so that folks can be reminded that not everyone with a mental illness should be locked up in a hospital with the key thrown away.

Hopefully, there won't be an opportunity for them to try my suggestion out but for various reasons, sadly, I feel there will be one in the future.


Dave Hannon said...

I think what you describe as the focus on the negative is actually a desire to analyze and quantify aberrant, violent behavior in order to understand it and hopefully prevent it.

Of course there are mentally ill people who are kind and caring and helpful and friendly. But by definition those people aren't out in society shooting people or in a psychiatric unit causing havoc. Studying them isn't going to lead to preventative care to avoid another Newtown or Colorado Springs.

catlover said...

Not sure I get your point, Dave. I was suggesting that for OTHER topics on this blog, that maybe there be some more articles that don't feed the stereotypes. ???

ClinkShrink said...

Thanks for the pic, Dinah. They're beautiful. Are we meeting for lunch today?

The challenge with positive stories about people with serious mental illness, as we've discovered while writing this book, is that those folks are difficult to find and extremely reluctant to step into the spotlight.

I agree there's too much coverage of negative stereotypes. I think there another problem though, which is that there's too little consideration given to the "real" violent mentally ill once they are institutionalized. There's a "lock 'em up and forget 'em" problem. Once out of society, who cares?

People may stand outside the walls and point fingers or wring their hands when something goes wrong, but few are willing to step up to the plate to invest the time and money to make the situation better.

The other issue I think is that there has been so much emphasis on reduction of certain interventions---single cell housing in prison and use of seclusion or restraint in hospitals---that we've hit an inflection point in public policy where institutions are becoming more dangerous. Some states have faced legislation to completely bar the use of single cell housing. This leaves little alternative for keeping other institutionalized people safe from those who have proven themselves dangerous.

As Dr. Seager said in his interview here, “We’re getting the shit kicked out of us and no one cares. Not just the staff, the patients."

ClinkShrink said...

The problem isn't limited to secure facilities. See this story from the Minneapolis Star-Tribune. From the article:

"According to a recent Star Tribune analysis, nurses are be­ing at­tacked in re­cord num­bers. This year, nurses have filed 46 work­ers’ com­pen­sa­tion claims for at­tacks and in­ten­tion­al in­ju­ries suf­fered while on duty in hos­pi­tals, the an­aly­sis found. The num­ber of at­tacks is on pace to double that of 2012 and 2013."

Joel Hassman, MD said...

"According to a recent Star Tribune analysis, nurses are be­ing at­tacked in re­cord num­bers. This year, nurses have filed 46 work­ers’ com­pen­sa­tion claims for at­tacks and in­ten­tion­al in­ju­ries suf­fered while on duty in hos­pi­tals, the an­aly­sis found. The num­ber of at­tacks is on pace to double that of 2012 and 2013."

Gee, I wonder what that is due to. You think the dumping of Forensic cases into the general mental health population not only in state facilities, but more and more into acute private ones as well, is making psych hospitals defacto jails?

Yeah, but no security guards with real effect on a moment to moment basis on such units? Keep rationalizing and minimizing away this issue. And god forbid we start needing "correctional officers" on psych units!!!

Sorry, I strongly disagree, I can't manage nor control violence with the training I have had. And I think it is time for Forensic Psychiatry to wake up and stop codifying violence and hate as simply psychotic disorders that clinicians are the front line to treat. Again, anger is a symptom, and if the cause is not amenable to mental health care that maximizes safety for all involved in the care process, then, why we have jails, and graveyards.

How many victims as providers should we tolerate before we have to reconsider who and what we are asked to "treat"? As in, "When to say When"?

ClinkShrink said...

Goodness, are you suggesting that any inpatient who exhibits violent behavior is a forensic patient, by definition? Do you really think that medical inpatients, or civil inpatients, can't be aggressive?

Joel Hassman, MD said...

If I played the odds from what I have seen during my YEAR of working at Finans Center, I would have no problem betting that over 75% of the violence there was by Perkins patients made to be accepted by Finans. Tell us why for every patient they legitimately sent back to Perkins, Finans had to take TWO in return. And then these patients HAVE to stay on the unit for at least 6-12 months. What is that Clink?

You know it is a dump, but, you won't say it because I think you are part of the system that promotes this agenda. And people like me who are forced to be these babysitters and untrained wardens for this inappropriate use of psychiatric beds for criminals, even if with a secondary Axis 1 diagnosis, resent the dumps.

Oh, and those who are legitimately with primary Axis 1 disorders, they seem to find ways to reduce their violent tendencies if provided care in an eclectic manner, and not just push drugs en masse. Do you think that is offered these days on psychiatric hospital units?

Goodness, do you really want to claim forensic cases on psych units are interested in receiving care? I didn't see it, and encourage any and all reading here who work inpatient units these days and have to accept forensic referrals to basic psych units, exactly what do they see. Please, refute me, I honestly would like to hear my experience was an exception.

Oh, and at times Axis 1 patients seem to be getting more agitated being led on to act out by the forensic "patients". Some are there just to watch the world burn.

Frankly, per an earlier commenter's point about paternalism. that model is a double edged sword, so wanting to make patients accept being told what to do in this day and age won't be so effective. That paradigm works better in correctional facilities, and even there it is marginally effective at best.

Yeah, I am fairly passionate about this issue, because the game plan ain't working for the staff and patients at the end of the day.

ClinkShrink said...

Promotes an agenda? An agenda of allowing patients who have made progress to move forward to a less restrictive, lower security setting? OK, sure, I'll agree to that. That's called treatment. I'm sorry you're not interested in that.

So readers, here's the dilemma forensic psychiatry faces. In order to move mentally ill folks out of an institution you have to have providers willing to treat them in the community. If you don't have that, all the involuntary treatment laws in the world won't help.

Anonymous said...

The poor stooge that gets branded as mentally ill is usually "the last one holding the dog collar" (from the film Zero Dark Thirty). Until we begin ferreting out and incarcerating every frenemy, hotheaded neighbor, family member, landlord, cop, employer, and clinician who runs roughshod over the designated nutcase, the focus of mental health treatment needs to be placed on helping the client recover from trauma and, where possible, bringing the client's perpetrators to justice.