Focus should be on fixing system, not punishing patients for hospital violence, mental health advocates say

To prevent violence in hospitals, the state should focus on fixing the mental health system’s failures, not on punishing individuals, according to those who have experienced mental health challenges and sought treatment at hospital emergency departments.

The individuals who spoke to the Sun Journal, most of whom are certified intentional peer support specialists, said they are deeply concerned about the legislative task force studying the issue of violence against health workers and the process by which criminal cases may be brought against those perpetrators.

Nearly a dozen doctors, nurses and administrators from area hospitals interviewed by the Sun Journal this year said they are frequently physically or verbally assaulted by patients or the people who accompany them. They said it is of particular concern for workers in emergency departments, intensive care units and psychiatric units.

When patients became violent with them, the hospital workers said, often, but certainly not always, the patients are there for a psychiatric or behavioral reason, including drug or alcohol intoxication.

They said when an assault turns physical, staff are generally hesitant to call law enforcement or pursue charges “because of the milieu in which they work,” one hospital president said.

When they do pursue charges, the providers said oftentimes law enforcement will decline to elevate the case to the district attorney, or the district attorney will refuse to prosecute. The reasons why are unclear and leaves them with little recourse, they said.

This “frustration” with the criminal justice system is why the task force is examining possible criminal remedies to violence in health care settings, task force Co-chairman Sen. Ned Claxton, D-Auburn, said this month.

“The criminal focus (is) really more a concern about the process that exists now and how it’s instituted and less about adding criminal categories or charges,” he said. The task force held its first meeting this month.

But the possibility of an enhanced criminal response to those who commit violence against health care workers concerns mental health advocates.

“It just seems like a very counterproductive approach to be taking for such a complicated issue,” Carly Mahaffey, 40, of Lewiston said.

Mahaffey and the others interviewed by the Sun Journal instead described the ways in which Maine’s mental health system can be improved to reduce violence in health care settings, particularly in emergency departments.

They said they are being left out of the conversation about hospital violence and worry that without their input, the solutions being considered at the state level could make the situation worse.

They called for nonclinical alternatives to emergency departments for people in crisis, for more training on how to care for people experiencing a psychiatric emergency, and for peer support specialists to be embedded in every emergency department in the state.

MORE TRAINING, PEER SUPPORT NEEDED

The individuals interviewed described the loss of a sense of control they felt when they entered an emergency department for help during a mental health crisis. It’s an experience “that strips you of your dignity and your rights,” said Jenny McCarthy, 46, of Raymond.

“There’s so much expectation on the patients to remain calm and civil and do as they’re told and not speak up and not saying anything,” she said. “But the environment in itself is really traumatizing to be in.”

“We expect (health care providers dealing with) mental health emergency crisis situations to be trained in trauma-informed practices,” but they’re not, said Julie Potter, 44, of Gray.

Trauma-informed care describes a clinical and organizational framework for care developed by the federal Substance Abuse and Mental Health Services Administration.

According to the administration: “A program, organization or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff and others involved with the system; and responds by fully integrated knowledge about trauma into policies, procedures and practices, and seeks to actively resist re-traumatization.”

One key element to a trauma-informed approach is peer support.

“It’s hard to understand something that you don’t have an experience about, which is why peer support is so important,” Potter said.

Peer support can describe any connection between people with shared experiences. When referring to peer support or peer support specialists, the people interviewed for this story are referring to a Maine-specific program where individuals with lived experience with mental health challenges can receive training and certification from the Office of Behavioral Health to work in hospital emergency departments.

Peer support specialists “utilize training and lived experience to help individuals in crisis by providing support to de-escalate acute situations, assist individuals in self advocacy and provide a connection to recovery supports in the community,” according to the Office of Behavioral Health website.

Peer support “takes us seriously,” and is able to de-escalate a situation, or prevent an escalation from happening in the first place, by helping guide a person through their emergency department visit, said Joe Bennett, 56, of Hiram.

A Penobscot County woman in her 50s, who asked to remain anonymous for privacy reasons, said when she was involuntarily admitted to a psychiatric unit on multiple occasions beginning in her 30s, providers “never asked me about any trauma, they never addressed my trauma.” At the time, she was in an abusive relationship, she said.

Earlier this year – two decades since her first hospitalization – she was finally diagnosed with post-traumatic stress disorder.

In the absence of a diagnosis and proper treatment, she said peer support is what gave her the tools to heal from that trauma.

“I learned how to be independent. I learned how to think for myself,” she said.

Seven hospitals in Maine contract with the Office of Behavioral Health to provide peer support services: AR Gould Hospital in Presque Isle, Central Maine Medical Center in Lewiston, Mid Coast Hospital in Brunswick, Northern Light Eastern Maine Medical Center in Bangor, Northern Light Mercy Hospital in Portland, St. Mary’s Regional Medical Center in Lewiston and York Hospital.

McCarthy said she’s frustrated by hospitals which “speak out about the violence,” but don’t offer peer support specialists in their emergency departments.

She and Bennett said Maine Medical Center in Portland, which has one of the largest emergency departments in the state, “refuses” to contract with the Office of Behavioral Health for peer support.

“Behavioral health patients have unique needs that require a robust continuum of care in order to be treated effectively,” a spokesperson for MMC said in a statement to the Sun Journal. “Peer support services should be part of that continuum of care and made accessible in a setting that works for both patients and other health providers.

“MMC utilized certified intentional peer support specialists in its emergency department for several years,” according to the statement. “Following an evaluation at the end of the contract period, MMC determined it should pause the deployment of these resources in its emergency department, which is the state’s only Level I trauma center. Maine Behavioral Healthcare currently provides MMC’s emergency department with one-call peer support as part of its substance-use recovery coach program.”

The statement also said MMC staff receive regular training for how to provide care for behavioral health patients in the emergency department and “encourages continued investment in the continuum of behavioral health services across Maine and New England.”

ALTERNATIVES TO EMERGENCY DEPARTMENTS

The peer support specialists all said Maine needs alternatives to emergency departments for people experiencing a mental health crisis.

“Too many people (are) using the ED when they’re not supposed to,” Mahaffey said. “It’s because they have no one else to talk to or they have nowhere else to go.”

Having more community-based and peer-led alternatives to an emergency department will also help reduce the crunch on hospitals, she said.

M.T. said her first experience being hospitalized for a mental health emergency was in 2005, a few months after she said she was sexually assaulted by a co-worker.

The 41-year-old, who asked only to be identified by her initials for privacy reasons, said emergency department providers and staff are not “adequately trained to deal with patients experiencing psychiatric issues and frequently add fuel to the fire.”

While not a peer support specialist, M.T. said she has about a decade of experience as an emergency medical technician.

“Patients deserve to be heard (and) properly diagnosed and treated by adequately skilled providers,” she said. “All providers who interact with behavioral health patients,” whether they be medical, law enforcement or fire and rescue professionals, need to be better trained.

Last year, she said she attempted to kill herself. While waiting for a bed at an inpatient psychiatric unit to become available, she said she sat in the emergency department at Stephens Memorial Hospital in Norway for four days.

The only placement available to her was at Northern Maine Medical Center in Fort Kent, an Aroostook County town at the tip of northern Maine and a 5 1/2 hour drive from her home in South Paris.

Having a patient sit in an emergency department for days at a time waiting for a bed to open up is a “recipe for disaster,” said Mark Joyce, the managing attorney for Disability Rights Maine’s mental health advocacy program.

Maine needs more peer-led crisis respite centers, Joyce and others said. These are nonclinical settings where anyone can go and speak to a peer support specialist, learn about treatment resources or “just take a break,” in Mahaffey’s words.

“I think it would lessen that number of people ending up in the ED and having to go through those traumatic experiences,” Mahaffey said.

Earlier this year, Portland-based Spurwink, a behavioral health and education agency, in partnership with Maine’s Department of Health and Human Services opened the Living Room Crisis Center at 62 Elm St. in Portland. It’s the first of its kind in the state, Gov. Janet Mills said when it opened in March.

“If it’s not the right environment for them, they can leave,” said McCarthy, who wants to see more crisis centers like the Living Room throughout the state.

“That violence is taken away because they can leave,” she said.

‘THAT’S A TREATMENT FAILURE’

The legislative task force is only looking to charge violent individuals who have the legally defined mental capacity to be held responsible for their actions under Maine laws, Claxton, the co-chair, said this month.

That’s not much reassurance for Joyce, who has worked 21 years at Disability Rights Maine, the state’s designated advocacy organization for people with disabilities, and also serves as the class counsel for the Augusta Mental Health Institute consent decree.

If the task force is only focused on individuals not being hospitalized due to their psychiatric disability, “that’s one thing,” he said.

But he wondered if it will “bleed over” to individuals who are hospitalized for their psychiatric disability and who become violent as a result of their disability.

“I’ve talked to a number of individuals throughout my career who have been blue papered (involuntarily admitted) being charged with crimes,” Joyce said.

Under Maine law, to involuntarily admit a patient, meaning they cannot leave on their free will, a medical practitioner must certify that they pose “a likelihood of serious harm” either to themselves or others, as demonstrated by recent suicidal, homicidal or violent behavior, or behavior that demonstrates an inability to avoid risk or injury.

“If you bring a person to the ER for any of these three particular reasons, involuntarily, and they’re stuck there for two or three days, I mean, that’s a recipe for disaster,” Joyce said.

If a patient is in an emergency department for an extended period of time after a doctor has certified that the patient is at risk of harm to themselves or others — and they cannot leave the emergency department for that exact reason — “and then they act on it because of the fact that they aren’t in the correct treatment environment, that’s a treatment failure. That’s a treatment failure for that person,” he said.

“The whole reason behind the law is that we’re saying at the beginning (that) we don’t want to charge you with a crime (for harming yourself or others), we want you to get treatment . . . and then if the end point is they get charged with a crime, that just turns the whole . . .  system on its head,” Joyce said.

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