Making Sense of Violence at Psychiatric Hospitals

So, it is essential for us to try to understand the issue of provocation and learn how to avoid it. In this case, I did the American thing: I blamed the victim and punished him more for something with which he might have had nothing to do. Our job as a staff in a psychiatric hospital, school, or a court is to determine the facts and to help the patient – not provoke him.

If I were to investigate the murders at Perkins Hospital in Maryland, I would see whether we could find out what provoked these patients. They weren’t on alcohol or drugs. And we know that patients with serious mental illness are not generally violent. Something happened in each case that led to the violent outbursts and to the deaths.

NAMI of Maryland has become involved in this problem, and the organization has said some things that are valid and important, such as calling for "a specific focus on missing warning signs that may have existed, treatments and interventions that might have prevented the tragedy." It is looking for some general provocation or medication that can be blamed. I am suggesting that the problem lies in human error. Just as in my example, small units can make a huge difference. I might have gotten thrown into the nursing station instead of the water fountain. Our goal must be to find simple solutions to complex problems.

Another possible cause for the violence might lie in the relationship of the patients to one another. I can recall a patient who looked dangerous and scary to everyone. Who would share his bedroom? He was wild looking; the hair on his head and face made him look like someone out of a movie – scary and violent. He was not the kind of patient you would ask to sit down for an informal conversation. I can recall visitors commenting on his frightening appearance and asking that he not be put in the same room as their son or their husband.

NAMI released a statement after the third killing in Maryland. At one point, it reads: "In general, people with serious mental illness are not violent. Acts of violence are exceptional. When violence does occur, it is generally a sign that something has gone terribly wrong." These are important truths. As we try to better understand what went wrong in the hospital, we have to keep in mind that we are trying to deal with human beings who have gone out of control.

What grudge does one of these patients have against the other? Living in the tight quarters of a psychiatric unit, a great deal can happen or be said that might cause the other person to nurse a grudge and carry out his nefarious plan days or weeks later. The existence of three incidents within a year in the same institution looks very suspicious. The first thought people will have is that something is going wrong in the hospital. Some might speculate that a psychiatric attendant is being cruel to the patients, or something along those lines. Such speculation would be wrong, as I have said. We have to be fair, despite our zeal to find an explanation.

A Call for Compassion

For the last 20 years we have truly attempted to humanize the hospital care of serious mentally ill patients. We have closed large state hospitals, made smaller institutions, gotten rid of seclusion and restraint, and done away with many of the punitive treatment methods that we used decades ago. In hospitals that used to have hundreds of patients, there was never enough staff to care for them in a humane way. By and large, that is a condition that has been corrected throughout the United States.

Hospitalization of patients with serious mental illness is becoming rarer nowadays. The length of stays is short, and hospitalization is used for "stabilization" of the patient and rather than cure, as we used to do years ago. This change should reduce violence in the hospital. I am often the doctor in our hospital who suggests keeping the patient a little longer to try to better understand his or her condition and circumstances. I don’t like to discharge patients when we’ve done nothing for them and have no way to protect them when they are out in a public domain and are much more likely to be to provoked by family and friends in the street.

The basic question is: How can we prevent violent behavior from occurring in maximum security state hospitals? There are, in many states, state hospitals for the criminally insane that are dangerous places. Farview State Hospital in Waymart, Pa., was considered one such hospital. (It has been repurposed as a correctional facility.)