Making Sense of Violence at Psychiatric Hospitals

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.

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.)

Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:

• Be sure that staff is sensitive and able to talk to patients.

• Train staff to recognize patient escalation and to search for causes before the explosion.

• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.

• Discharge patients who are troublemakers.

• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.

These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.

Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.

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.

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.)

Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:

• Be sure that staff is sensitive and able to talk to patients.

• Train staff to recognize patient escalation and to search for causes before the explosion.

• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.

• Discharge patients who are troublemakers.

• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.

These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.

Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.

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.

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.)

Here are a few rules aimed at reducing the kind of violence that occurred at the hospital in Maryland:

• Be sure that staff is sensitive and able to talk to patients.

• Train staff to recognize patient escalation and to search for causes before the explosion.

• Carefully select patients who are housed together on a unit. Do not risk mixing patients who truly look like they’re going to explode.

• Discharge patients who are troublemakers.

• Use daily group sessions of patients to discuss staff concerns about violence, and so on. We have learned over the last few decades to include patients in unit decision making.

These are just a few suggestions. All of us in psychiatry must pay attention to these problems. When events like this occur, they increase the stigma against psychiatry and exacerbate the ridicule too often heaped on us and our patients. So this is a community issue, and EVERY psychiatrist has a role to play in trying to discover a solution.

Dr. Fink is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.