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Caring for staff?

Recent program cuts at the Brattleboro Retreat highlight increased violence toward staff members

BRATTLEBORO—Program cuts announced on Nov. 14 during union contract negotiations have some Brattleboro Retreat workers concerned that an already rising problem of patients’ assaults against staff at the psychiatric hospital could escalate.

The Retreat announced last week that 31 of its staff would lose their jobs as the hospital cuts two programs: Therapeutic Activities Services (TAS) and inpatient chemical dependency councilors.

The number of teachers in the Meadows Educational Center, the Retreat’s private school, will also be reduced.

A handful of administrative employees were also laid off, and more staffing cuts might lie ahead.

The cuts come at a time when the Retreat workers are dealing with an increasingly challenging clientele.

According to Peter Albert, a licensed clinical social worker and a Retreat senior vice president and spokesperson, over recent years patients have come to the facility with more complex needs, placing more pressure on the hospital and prompting the Retreat to shift its programing.

Patents once routinely arrived at the Retreat with one diagnosis, such as depression. Many patients arrive now with multiple diagnoses.

A typical patient might be diagnosed with depression, a substance addiction, and physical health issues, to name one example of a constellation of behavioral and physical disorders.

“It’s important to recognize the people we’re treating have significant mental illness,” said Albert.

Union President Bonnie Chase said it is reasonable to expect that reducing staff will reduce the number of people available to care for an increasing number of patients — a vicious cycle that she predicts will contribute to increased injuries.

Christine Gray, a Retreat float nurse — one who splits her time among the Retreat’s various programs — said she and some of her colleagues expect that a number of patients will face increased need for medication on the units, absent a therapeutic services program and addiction councilors.

Patients learn coping skills in these programs, she said. Without such skills, medication becomes a patient’s next avenue of symptom management.

Gray said the children’s programs will feel the loss of TAS most keenly because the therapeutic activities are “intrinsic” to their care.

Assault on duty

Laura Lodge, a mental health worker (MHW), described how a patient violently assaulted her and a colleague on Sept. 11.

According to Lodge, a male patient knocked her to the ground and beat her in the back of the head multiple times. Pinned to the floor, she could not reach the alarm.

Another female colleague heard her screaming. The male patient “turned on” the second woman, she said, and then returned to attacking Lodge.

Lodge said she was treated by medical staff at the Retreat and then sent to Brattleboro Memorial Hospital for further tests.

By her account, the assault left her with severe black eyes, “eggs” on the side and back of her head, and eight stitches.

The other woman has some “brain damage,” said Lodge.

“He knew what he was doing,” said Lodge of the male patient.

Lodge contacted the police to file charges. The officer filed a full report and photographed Lodge’s injuries, she said.

According to Lodge, however, the officer told her, “Nothing will be done.”

She said that she was told the Windham County State’s Attorney will not prosecute because the assaults are “an acceptable part of my job,” added Lodge.

Windham County Assistant State’s Attorney David Gartenstein said that in Vermont, police have the authority to prepare charging documents and refer them to the state’s attorney.

Gartenstein said he was not aware of anyone being discouraged from making a report to the police. The state’s attorney said he would not discourage people from making a report to the police, either.

The state’s attorney’s office reviews reports from such incidents at the Retreat and makes independent decisions about each report, he said.

The process to determine whether to prosecute patients in a psychiatric facility “involves complicated issues related to a defendant’s capacity to participate in [court] proceedings,” said Gartenstein.

A person’s “competency” and “sanity” affect the ability to prosecute, said Gartenstein.

According to Lodge, the male patient hurt two other staff.

Lodge alleged that “[management] is just trying to cover it up,” she said, also charging that her supervisor, a clinical manager is “now on the outs with the administration” after advocating for her.

Will Shafer, a nurse, said the Retreat “is not set up for” the complexity of its current patient population, and he said that the hospital is putting its staff “in harm’s way.”

Shafer said the hospital needs better alarm systems, for starters. He added that the hospital is also starting to mix the more acute, and potentially violent, patients with other, less-dangerous, patients from other units.

This strategy puts not only staff but also other patients in harm’s way, Shafer and Lodge agreed.

The two staffers said they worry for the young, new mental health workers who are left alone to watch “assaultive men” during their shift.

Shafter said that the male patient who had attacked Lodge was moved to his unit. He would not have known the patient was dangerous if Lodge had not called to tell him.

Lodge also said that “there’s not enough staff” on her unit. Routinely, staff members from a previous shift must work a following shift to make up the numbers, she said.

The “forensic” patients — a population that comes to the hospital under the directive of the judicial system — stay at the Retreat longer, sometimes months longer, than patients in the hospital’s other programs do, she said.

Not having the therapeutic activities “damages their care,” Lodge said.

The Retreat’s stance on safety means patients aren’t safe from one another, she added.

“[The Retreat] is acting reactively to the assaults, not proactively,” said Shafer.

When asked if the Retreat had to adjust its training for staff to address the issue, Lodge responded, “You can’t train for being assaulted.”

Police activity

According to Brattleboro Police Chief Eugene Wrinn, the department’s responses to calls originating at the Retreat have decreased. These calls included everything from pulled fire alarms to injuries.

Starting in 2007, the police responded to 142 calls, said Wrinn. Those numbers decreased each year to 56 in 2011.

But etween January and June of this year, the department responded to 38 calls. Wrinn felt this number was “on par” with trend toward decreasing.

Thirty-eight calls in five months, however, reflect a rate of increase of roughly 37 percent over the previous year.

Wrinn said his department has met with the Retreat to discuss how the police can best cooperate with staff to ensure everyone’s safety.

The police want to protect the community, said Wrinn. But the department wants to steer clear of interfering negatively with a person’s therapeutic care, he said.

Wrinn said the the hospital has developed a solid process for when to involve police. He added that the long run of decreasing numbers of calls to the Brattleboro Police Department reflects the Retreat taking proactive measures.

The Commons has obtained data from the state’s Department of Labor and Industry, Division of Workers Compensation listing injuries to Retreat employees spanning Sept. 2011 to Nov. 2012.

According to a brochure from the Vermont Department of Labor, “An employer must promptly report all work injuries that result in either an absence from work or require medical attention.”

Off the 55 injuries listed, 14 centered on employees injured by patients through “hitting,” being “struck,” “punched,” or “attacked.” Of the 14 listings, eight had the code description “head — multiple injury.”

Careful not to re-stigmatize

It’s important during this conversation to guard against re-stigmatizing patients who are managing mental illness, said Albert, the Retreat senior vice president, who is concerned that attention drawn to staff dangers could reflect unfairly and inaccurately on the majority of the hospital’s patients.

Most people with mental illness are not violent, he said, pointing out that they instead withdraw.

The Retreat has increased staffing on units, he said, but added that increased staffing is not the only solution.

During recent renovations in the buildings, the hospital contracted with an architect who specialized in designing mental health facilities.

The hospital wanted to use the units as “therapeutic tools,” said Albert. The new designs decreased the number of beds and increased the number of quiet spaces that patients could use.

Albert said the Retreat has also engaged in more trainings and debriefings of staff after incidents. The hospital has also formed a Consumer Advisory Group comprised of past patients and professionals to help work with staff and patients on ways to move forward.

He added that during job interviews the Retreat does not pussy-foot around the variety of ways mental illness can “manifest” in a person’s behavior.

“I’m not dismissing [the staff’s] concerns,” said Albert, acknowledging the more complex diagnoses of the patient population. “We all need to appreciate that’s what our work now is.”

According to Albert, staff have access to an employee assistance program, which connects staff with psychiatrists and other resources.

Albert also said that staff can request to make a formal report to law enforcement, but the Retreat tries to educate staff about the challenges of prosecuting a patient with mental illness.

Staff have a “tough job,” said Albert, who said that hospital staff should feel free to voice concerns.

And if Retreat staff don’t feel comfortable doing so, “then that’s a piece we need to work on with people,” Albert said.

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Originally published in The Commons issue #179 (Wednesday, November 21, 2012).

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