Today’s NPR Morning Edition is reporting on high levels of violence in California state psychiatric hospitals, leading to hospital staff demonstrating for safer working conditions:
Last year, staff members were attacked by patients more than 1,300 times — nearly double the number of assaults from the year before. Meanwhile, patients assaulted other patients at a rate of almost seven times a day.
Curiously, the article contains no quotes from patients or their representatives, or patient advocacy groups. The quotes in the article are from hospital staff, management, and assembly staff, and they emphasise primarily the importance of staff workplace safety, not patient healthcare safety, although it seems to me that both are equally important, and crucially interconnected.
Speaking in very general terms: the research concensus is that people with mental health conditions are very unlikely to be violent, and where people with mental health conditions do engage in violence it tends to be associated with alcohol and drug use. However, people with mental health conditions, and disabilities more generally, are at very high risk of experiencing violence or harassment.
So when I hear a story like this one in the California psychiatric hospitals, I wonder what’s going on in that hospital, because I’m discinlined to believe the cultural stereotype of “crazy people do crazy violent stuff”.
My own experience of caregiving (mostly of children, which I realise is not quite the same, but I still think there are useful things to be learned), is that the people receiving care can sometimes hurt other people in the following two types of situations:
- if they were experiencing sensory overstimulation (in the cases I saw of this, I think the child usually did not realise they were hurting someone, and we had various short-term strategies for helping the kids manage overstimulation. In the longer term we also try to teach them that certain actions do hurt people).
- if the child didn’t understand what was happening around them, and got confused and upset because of it, especially if there was a communication difficulty involved. This is the most common reason in my own experience.
Many of the kids I’ve worked with had specific difficulties with communication. If a non-disabled person is engaged in a task, and suddenly someone hauls them away from it without explanation (of course we would never haul a child away from something, or change an activity without explanation, but for a kid who takes several minutes to process an activity change, it might have felt like that if as carers we hadn’t explained things to them the way they needed us to, or set aside enough time to do so), of course you’d feel threatened and frightened, and you’d lash out. So managing this situation to support the person (and the carer) is about learning how that person needs to structure their activities, how much advanced notice they need of a change, how to communicate with them effectively if something unplanned happens, etc. This is all doable, but you need a consistent team of staff who take the person’s concerns seriously, who are flexible and well-trained, who can communicate well with other staff about what strategies are in place to support that person, and who have the time to devote to making sure that person gets the support they need. I’ve also seen major anxiety (though not violence) arise with an older person in similar situations, and the caregivers didn’t have the time and knowledge to adjust their communication the the person’s needs.
This should resonate with most non-disabled people’s experiences too: assuming you are not the sort of person who hurts other people for fun, and you have good intentions, the situations in which you are most likely to hurt someone else are probably something like: you feel seriously and imminently threatened or hurt by someone else, or it’s an accident and you don’t mean to hurt anyone.
Now in this case we’re talking about adults, so I suspect that accidental situations are probably less of an issue than with children. But if, for whatever reason, the patients in this situation do feel desperate or threatened, or are struggling with other ways of communicating, it seems to me that we can start to understand how the violence arises. This is not because I think it makes violence ok, but because I think we have to understand why the violence arises in order to address it.
But I do note this from the NPR article:
Metropolitan Hospital’s medical director, Dr. Michael Barsom, says there’s no conflict between management and staff on what should be done.
“I think the conflict, as it were, arises from what is feasible to be done,” he says. “So to hire more staff, to hire more police officers, to implement an alarm system are very expensive items. And we’re limited in what we’re able to do.”
So the hospital staff and management are saying they want more staff and resources to manage the situation. This resonates with what I was saying above. Supporting someone may well require a consistent time investment from well-trained staff. And yes, in the long run, that costs money.
So that’s my couple of penneth worth as a caregiver. But as a disabled person, there’s a bit more. The LA Times coverage notes that some of the plans in place to deal with violence in psychiatric hospitals don’t focus on funding and making sure staff and patients are well-trained and well-supported, but rather on:
Among them are bills that would enable officials to [...] speed up the process to involuntarily medicate certain individuals and punish those who funnel contraband — such as tobacco and cash — to patients,
This ties in closely with the narrative of the “good cripple” that other activists have written about — s. e. smith has a good intro here. In a nutshell, the idea is that if you are disabled, you ought to gratefully accept what has been chritably done for you, not be demanding. You must behave such that you are the model of responsibility, in order to be deserving of the charity that others give you, always bravely trying to overcome your suffering. If you fail to do these things, you’re being ungrateful and difficult, and it is (so the idea goes) legitimate to withhold adjustments and support from you.
Now call me cynical, but it sounds to me like the assaults in this hospital are probably not caused by tobacco. Nor is it clear to me why a psychiatric patient should not be allowed to smoke by law (in the UK, many psychiatric hospitals do have designated smoking times when patients can be escorted outdoors by a member of staff to smoke, which strikes me as being perfectly sensible). There may be a few situations in which violence is associated with not taking medications, but it won’t be many, since we know that mental health does not inherently make a significant contribution to the likelihood of violence.
So if the legislative response is to making it easier to punish patients with things that are not related to the violence and won’t help manage the violence, it seems to me that they’re relying on the “good cripple” narrative. I’ve written before about the effect of the “good cripple” narrative on mental health.
Why does that matter? Well, I suspect that managing the violence effectively in this case will be more effectively resolved with measures like more staff and more training. That’s in the interests of the staff as well as the patients, but we can only get there if we give up harmful tropes like the “good cripple” narrative and the “crazy people do crazy violent stuff” stereotype. Because of course it’s important for staff to have a safe working environment, and of course as it’s important for disabled people to have safe access to healthcare, and a safe living environment if that healthcare is inpatient. And I was a little pissy to note that the first was being emphasised in the articles, and the quotes they used, but less so for the second.
Also, NPR? I expect more analysis and less reliance on cultural stereotypes. That was pretty sucky on the investigative journalism front.
–IP
