There is good reason for the Legislative Council to delay approval of Gov. Paul LePage’s plan for a new facility at Riverview Psychiatric Center to house patients found not guilty of crimes because of their mental illness and who no longer need hospital-level care. It would be folly to think bricks and mortar alone will solve the problems at the state’s troubled facility. We have a long history of addressing mental illness with isolating institutions that separate people with mental illness from communities as others.
That otherness persists in how we talk about those with mental illness: that “violent patients” or “dangerous forensic patients” are wreaking havoc on budgets and limiting access to treatment beds. But we must tread lightly here. By taking the manifestations of illness as defining characteristics, we are limiting the potential for illness management. We are also hindering human and legal rights, and we are placing caregivers in danger.
In fact, patients who act aggressively toward themselves and others are not criminals. They are people in the throes of illness who need effective treatment. This is why the law directs them to be hospitalized instead of tried or imprisoned. There they are evaluated to determine capacity for trial or treated for safe return to the community. Some with extremely complicated conditions may never manage behaviors safely. But even those who stay in the custody of the state will benefit and be easier to care for with the appropriate care and treatment.
Before we build a new facility, we must understand patients so we can build responsively. Forensic patients are accused of crimes, and it is instructive to consider the characteristics of convicted criminals. More than half of all prisoners have some form of mental illness, a quarter of those have been sexually abused and many were exposed to substance abuse and domestic violence. And exposure to adverse childhood experiences like these predicts mental illness, substance use, violence and involvement in the criminal justice system.
Between 25 percent and 87 percent of prisoners have a history of traumatic brain injury, compared with 8.5 percent of the general public, and head injuries can affect judgment. These facts are not meant as excuses for violent behavior, but should indicate the type of treatment that can be helpful for these people.
In 2013, Riverview lost its federal certification in part because regulators found that sheriff’s deputies at the facility used stun guns and handcuffs to restrain patients. These measures can exacerbate symptoms and re-traumatize patients. That is not treatment nor care.
The standard of care for patient populations with histories like these is complex. In addition to being trauma-informed and gender sensitive, the entire culture of a facility must be positive and therapeutic. That means in addition to adequate numbers of staff, they must be fully trained, supported and supervised to actively and consistently contribute to a culture of care in which there is an expectation of improvement. The science and the experience of forensic units around the country are demonstrating that negative, punitive approaches are not effective in changing behaviors.
Maine is not alone in struggling with dangers in forensic units. But a growing number of states are embracing new standards. In Connecticut, the Whiting Forensic Unit made the shift to evidence-based therapies, commitment to positive reinforcement and crisis prevention. The results were remarkable: The use of restraints and seclusion at Whiting dropped 88 percent.
The commitment to change spanned all levels. The unit’s director, Charles Dike, inserted himself in clinical decisions and shared problem-solving duties with staff and patients as they adjusted to the new culture. It was hard for many of the staff to see violent individuals as patients in need. But the result was a calmer, therapeutic atmosphere in which patients take responsibility and even improve in the management of their conditions.
LePage has pledged to use $3 million to $5 million to build a new facility to house forensic patients. Members of the Legislative Council have asked for more information about his plans. But it shouldn’t stop there. The Legislative Council needs to push for the administration to drop the “violent patient” language and commit to positive culture of care, not punishment or assault; ensure comprehensive training and support for staff to make the shift; and embrace the standard of care that includes positive, trauma-based, gender-sensitive crisis-preventing therapies.
And if we still need bricks and mortar to provide a healthy environment for care and rehabilitation, then the Legislative Council should approve the proposal for a new building at Riverview.
Moira O’Neill, a nurse, is a former assistant child advocate for the Connecticut Office of the Child Advocate, which oversaw state-funded services to children. While there, she met with staff at the Whiting Forensic Unit as part of a reform effort at two children’s mental health facilities. She lives in Surry.