Institutional Crisis
Mental Health Care crisis is causing injury to patients and staff
Having worked in an forensic psychiatric setting for many years (36), I have come to realize that, though I work in a human services, I am just part of a giant machine! The machine continues to work even as parts get replaced. As the song says, Just another cog in the wheel.
Many psychiatric aides, later known as mental health therapists, have come and gone over the years, injured by patients who show little regard for the damage they cause others. I don’t think they see a person, a parent, a son or daughter, a friend to someone! They see someone, or something, not doing what they want! Or, for the truly psychotic, the person may be responding to overwhelming fear or anxiety.
Some of these staff had a career ahead for themselves. Some had a job that would be beneficial while they were completing their degrees. Whatever their path had been, the violent interaction with the patient ended it and changed their life. Sometimes their life was changed in devastating ways, at other times they were just ready for a change of pace.
I have seen many staff who medicated themselves , using substances to try and numb the feelings that come from having to work with people in constant emotional crisis, having to often control violent people physically, and from constantly working in a state of continual mental readiness. I have to admit it is easy to fall into having a few drinks to try and quiet the mind at the end of a long day and to it is easy to get used to becoming comfortably numb. Some staff have moved on to other things while some decided to stay in their jobs and share their wisdom. Those that left have done so for many reasons. Some have been happy to have had the opportunity to grow in the experience and others were shattered by what they have been through. Most do not leave without some sort of trauma from what they have witnessed, and what they have had to be part of in order to keep the environment safe. Many will question their actions for years to come, wondering if they helped or hindered. It is only natural to question what we have been asked to do when working with clients who dance back and forth across the line that is boundary between personal freedom and infringement on other’s freedoms. It is the place where the philosophical is put to the test as it is pushed up against the reality that is interaction with fellow human beings.
This nation’s (USA-I’m in Oregon) embattled mental health system does little to protect the mental and physical well being of the health care providers who come to help the mentally ill, the forgotten of society. It’s not because there aren’t managers and other people in the system who want to help, there are. It is simply because the wheels of the machine are turning and no one is sure how to change the course of the machine! Mental health services are provided at no higher rate for the the mental health care workers than for the general public and, by the very nature of the business, it draws those who have an interest in mental health. This could include those who have a family history of mental illness, have been in the system themselves or have been affected in some way by the mental health system.
As an example of the system doing little to protect the mental and physical wellbeing of Health Care Providers within the system I will share the following scenario; It is decided that a certain action by the hospital or a staff person is neglect or abuse, the patients exercise their rights to have this curtailed, the hospital adjusts how it deals with the patients in order to fulfill the mandate to meet the patient rights. This then stops the neglect or abuse and opens the door for an assault to occur. For instance, seclusion & restraints orders used to be written for 12 hours at a time. This is extremely excessive for a person who de-escalates pretty quickly and could easily, and did, lead to being abused for convenience. So, this went to court and was found to be inhumane, really, because it was. So, the amount of time these orders can be written for was reduced, and other parameters were put in place (such as having a second opinion within 1 1/2 hours and the Chief Medical Officer involved after 4 hours. This was the right thing to do, it really was! It ensures that there are objective eyes looking at the situation. But, and I ask for people to reserve judgement, for the staff who have seen this “treatment” used for all time, there is suddenly a fear that if they use controlling measures for a person who is violent or threatening violence, they will get in trouble, have to give testimony to the investigators and possibly lose their job. Their reaction? Well, as expected, the reaction is to wait as long as possible before doing anything because the staff person doesn’t want to be seen as infringing on that patient’s rights. This leads to more injuries and less trust, more patient injuries, more staff injuries and patients and staff who don’t feel safe in the on unit environment, in the treatment malls, or the cafeterias, or schools, or vocational services. This also leads to staff confusion about what they can and can’t do. And if it leads to staff not knowing what they can and can’t do, you can be sure it leads to the patients not being sure what the expectations or boundaries are. Each day I see atrocious numbers of patient and staff injuries occurring. I hear the codes being called over the speaker system.
Why is it going this way? From my perspective it is going this way because people are not sure how to respond to change, or a change in expectations to be more precise. I know this to be true because I have personally gone running to a situation and had no idea what to do because each unit and each nurse has a different interpretation of what the rules and expectations have become. Do we have to wait to be punched? Or, can we tell the patient we are going to go hands on if he doesn’t stop threatening to hurt someone? Is the patient allowed to pace past another patient, glare at him and whisper “die”? Or, is that enough to say “stop, or you will be restricted in movement? These are the areas with staff on different pages and unclear expectations and boundaries that keep patients testing out what they are able to do. When staff aren’t sure, they try to stay as far from the situation as possible. It only makes sense, who wants to be the person who did the wrong thing?
At what point will this be taken seriously for more than just a couple of election cycles? I can’t say this is a fair statement to the political class. At least not from me. I really don’t follow the mental health budget closely in my state. So, the information I am getting is hearsay. I have testified at the legislature a couple of times. Once to share about the injuries I have received over the years and another time to share about our work on attempting to move away from an us against them mindset (corrections mentality) to a helping mindset ( I will happily share more about that in another article in the future).
The State Hospital system in Oregon is overwhelmed (I am speaking of mental health treatment services) and we have a hard time providing continuity of care for our mentally ill. There are breaks in services between the community and in-patient treatment. Not everyone falls through the cracks but I dare say that many have been coming in for evaluation and treatment only to time out for the alleged offense and be released by the county back to the street. This sets up a revolving door scenario for the patient because there is a lack of continuity of services and, if it is winter, often the necessity of committing a crime in order to find shelter, food and medications.
As noted above, the issue is the mental health system in Oregon is now at a place in which we are no longer able to keep up with the number of people being sent to the state psychiatric hospital by the courts for evaluation and treatment. This has caused a backlog in the jails and gotten advocacy groups concerned and involved. We now have few patients in the hospital due to Guilty Except for Insanity because, by court order, we had to make room for patients who are unable to aid and assist in their own defense in court. The Aid & Assist clients are more unstable and, thus, more dangerous. Most therapy is limited to preparation to return to court to assist in the defense of their charges. This is a large misuse of staff training and abilities, as well as available space a equipment. Many patients are unable to work on their aid and assist issues until they are stabilized with medications.
In summary, we have moved from a correctional, us against them mindset to a relational, come alongside and assist mindset. We are coaching staff in a relational approach to working with patients in a trauma-informed manner with the goal of building skills and preparing patients for a fuller life in the community. However, with a radical change in the client base to Aid & Assist from Guilty Except for Insanity, we are now operating at a crisis intervention level which is really not the best way to use these resources.
While I understand there is a need at the aid & assist level, I do hope we get back to the business of building skills with those who have been adjudicated so we can fulfill our Oregon State Hospital Vision, “We are a psychiatric hospital that inspires hope, promotes safety and supports recovery for all”
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