Three recent patient killings at a maximum security mental hospital in Maryland raise questions about prevention. What can be done to protect patients and staff in such hospitals?
I was dismayed to learn about the three tragic murders that took place in at the Clifton T. Perkins Hospital Center, a psychiatric state facility in Jessup, Md. The murders aroused a great deal of passion and discussion about why and how such things could happen amid so many safety precautions in psychiatric hospitals.
The occurrence of three such incidents within weeks of one another in the same hospital begs the question: "What is going on in that hospital?" It seems like a logical one that is being asked by all interested parties, particularly by the National Alliance on Mental Illness (NAMI) of Maryland.
In our search for a cause, I do not believe we can blame the hospital except with the issue of staff training. It is possible that the staff is unaware of what to look for when a patient is escalating; although, both patients with schizophrenia and those with mania give a lot of clues as they get angry or frustrated and feel the need to take it out on someone. Patients with paranoia are notorious for picking an enemy and relentlessly pursuing that person – usually not to his death – but with a great deal of violence. We also must keep in mind that as horrific as these incidents are, they are quite rare.
Each case must be looked at separately to discover underlying factors that led to the murder. In general, I think that certain provocations lead patients to act out against staff or other patients. And it is important to protect the patients and the staff from outbursts. This is best accomplished through staff training and in the daily groups that take place in most hospitals of this nature. Group meetings allow patients to report what they have observed, which is important data before something happens.
An Inadvertent Provocation
These issues remind me of an incident that occurred in my first year or residency about 55 years ago. It was in a private psychiatric hospital. I was in my office, which was located in a hallway leading to the patients’ day room in the recreation building.
At one point, I heard a sudden outburst of noise, so I went out to investigate. A large ring of people was yelling and jeering at a patient – who was in the middle of the ring. This fellow was my patient.
He was a very tall, muscular man with bleach-blond hair. The ring, it turns out, was made up of patients and staff. The patient looked very terrified.
I have no idea how I did it, but I walked right into the ring, took the patient by the arm, and led him into the building where his unit was located. We said nothing, but I think he was grateful to me for rescuing him. We walked up two flights of stairs, and I unlocked the door to his unit. Once safely in the unit, I made my mistake. I said very softly, "You know I’m going to have to take away your ground privileges."
He broke away from my grip on his arm, went over to the water fountain, which was electric and connected to pipes for the water. He ripped it off of its pipes and picked it up – that thing must have weighed about 250 pounds – and tossed it through the glass in the nursing station. Water was spritzing everywhere, and the staff was very upset. Ten attendants jumped on him, subdued him, and put him into the seclusion room. They had no idea that I had provoked the violent behavior. Over the years, I have reviewed this incident in my mind and have used it to teach residents not to provoke. It was clearly one of the stupidest things I’ve ever done.
I tried to analyze why I said it, and I feel sure it had to do with my own fear. Where did I get the guts to walk into the circle in the first place and get him back to his unit? I cannot comprehend this. Much of my behavior was tied to my effort to regain control of myself and the situation. Anyone reading this would know that that remark was gratuitous and totally unnecessary.
I tell the story to exemplify provocation. It does not have to be visible to everyone, but it strikes at weakness. Not only did the patient have the ignominy of being the target of bad treatment by 20-30 patients and staff members but had to be taken by the hand like a little boy to safety prior to my utterance. Over the years, I’ve realized that I was blaming him and further punishing him without even knowing what had initiated or instigated the event in the day room.