“We’re locked in now,” Craig Dacus said.
We walked into the north hall of Atascadero State Hospital, and the door shut behind us with a slight whoosh of air, as if we had just left a decompression chamber.
Behind us lay the security checkpoint that leads into the hospital—a rectangular room barely large enough to fit an air hockey table—where we waited with a few hospital workers as the guard behind thick, protective glass barked orders over a loudspeaker before unlocking the door into the hospital, one of the four high-security facilities in California for mentally ill offenders.
In front of us, the hospital seemed to stretch into nothingness. A puke-yellow hallway with drab tile floors and concrete walls pulled so far back into the building it appeared to collapse on itself at some point beyond where you could see.
Walking into ASH feels like being born—entering a world in which you’re completely clueless and helplessly vulnerable. A former psychiatric technician would later tell me that, on her first day, she thought she was going to die.
From the outside, ASH is a razor-wire-lined concrete monster of a building with a domineering presence in an otherwise serene Atascadero rural valley.
Inside, however, it’s harder to describe. Patients quietly shuffled through the hallway, a veritable highway with two lanes of traffic moving in opposite directions. They wore thin, khaki-colored pants and matching shirts, ambling in their slippers from one place to another.
“Stay close to me,” Dacus warned.
Dacus, ASH’s public information officer, wore a well-fitted black suit and tie as he clomped down the halls. We met and greeted hospital administrators who were eager to explain the various recovery programs and boast about other activities, such as hospital potlucks. They were adamant about focusing on positive things, like the group sessions or the reward system that allows patients to collect points for brushing their teeth or getting out of bed. Patients exchange their points for Chuck E Cheese-style prizes, including powdered fruit punch or AM/FM cassette players (CDs are contraband because of how easily they can be used as weapons) kept locked behind a wire-frame fence in a special day room. Dacus noted how that room even smelled better, carrying a wafting aroma of cleanser, unlike the sterile hospital air in other parts of the building.
ASH is an architectural testament to function guiding form. The hallways’ long, straight stretches present few corners or places to hide—at least in the north hall we saw.
“Use the mirrors,” Dacus said, motioning to convex mirrors lining the walls and positioned in the few corners where the hall bent in another direction. Without the mirrors, it seemed shockingly easy to get blindsided in that place.
“Mind the mirrors,” Dacus repeated.
We pressed on, touring the halls, meeting staffers, and popping into one of the hospital’s living units where about a dozen men sat in the day room, quietly watching TV. A man wearing a pair of headphones sat to the side, laughing happily.
“We’re not all crazy,” he said, barely able to get out the words over his own chuckling.
Patients are kept four to a bedroom, separated by flimsy walls between their beds, which are little more than thin sleeping pads atop shelves. At about 3 p.m., many patients were sleeping, curled in tight balls with their backs turned.
Farther back in the unit were two solitary rooms, both empty except for a thin foam mat in the corner of one room and an unoccupied restraint table in the other.
We made our way back to the security gate. As we waited in the small room and the guard eyed us skeptically before opening the door back to the main lobby, a few staffers traded bizarre stories about their day.
A tiny woman who looked like she’d just stepped out of a college prep course joked that she’d been told by patients she was both a vampire and a werewolf.
“At least you didn’t walk out of a dead body like I did,” her friend laughed.
Earlier, before entering the hospital’s innards, I met with Dacus and ASH Executive Director Jon DeMorales. Sitting in plush chairs at one end of a long conference table with the hospital spreading just beyond those thick metal security doors, our conversation danced around referring to ASH as something not quite like a jail, nor a typical private hospital, and still not comparable to a state prison.
In reality, ASH is a high-security forensic facility designed to house up to 1,275 men who are severely mentally ill—nearly half of ASH’s patients have schizophrenia—and have either committed or been charged with committing crimes. The all-male hospital houses patients in five categories, including mentally disordered offenders too unstable to be immediately paroled from state prisons back into the community, men charged with felonies but found not guilty by reason of insanity, and others who were turfed from a prison system lacking resources to treat mental illness.
Then DeMorales said something that caught me off guard: “I think some of our employees like to brag about how big our place is and how dangerous our place is.”
After speaking with longtime employees who have seen ASH undergo some of its most dramatic changes ever in the past five years, it’s hard to imagine anyone boasting about what the facility has become.
According to one person who’s worked there for two decades, “It’s getting more and more dangerous.”
Beginning of the end
In early 2006, the U.S. Department of Justice (DOJ) descended on the California Department of Mental Health (DMH) and assumed the role of babysitter to four California forensic hospitals: Napa, Patton, Metropolitan, and Atascadero.
It was the beginning of a new therapy model under a mandated Enhancement Plan, which then led to the Wellness Recovery Program. This new approach was in response to cases of staff abuse that triggered a litany of legal precedent. Staffers I spoke with admit there have been cases of abuse against patients in the past at most state hospitals, but such cases tend to be the exception rather than the rule. Mental health bigwigs were sent scurrying to implement new programs that would greatly reduce the chances a patient would be forced to take medication, be restrained when he acted out, or be otherwise “abused.”
“The extensive reforms required by the five-year agreement will ensure that individuals in the hospitals are adequately protected from harm and provided adequate services to support their recovery and mental heath,” the DOJ announced on May 2, 2006.
The new model created a softcore approach to treating patients, some of whom bounce between the hospital and state prison system, where they absorb a prison mentality. And it’s made punishing bad behavior or even discouraging it virtually impossible, employees say.
ASH’s former executive director, Mel Hunter, left almost immediately after the DOJ stepped in, and DeMorales was brought out of retirement to take over.
At the top of the list imposed by the DOJ was an attempt to ensure “freedom from unreasonable restraint, prevent regression, and facilitate their ability to exercise their liberty interests,” Assistant Attorney General Wan J. Kim wrote to state officials.
Thus began the great bureaucratic gutting of California’s forensic mental health program.
“Our entire effort has been geared toward meeting the requirements of the Department of Justice,” one ASH psychiatric technician said.
Another former psych tech remembered being part of a post-DOJ “takedown” of a patient who had been “cutting up another patient.”
“We’re trying to get restraints on him, and the psychologist is saying, ‘Now if we let you up, you promise not to be violent?’”
Internally, some staffers like to refer to the new methodology as “hug a thug.”
One man who’s worked at ASH for roughly 40 years said, “It’s always been a dangerous place, don’t get me wrong. … There’s just been this shift to allow the influence of a certain philosophy to take place, and it’s just made it much more dangerous.”
Beyond the new recovery model, the DOJ and a team of court monitors did what bureaucrats and consultants do: They created a plan and assigned mounds of paperwork to document and justify it. Employees now spend much of their time filling out charts and rarely interacting with patients as they used to. Staffers call it “treating the chart” or joke that they spend more face time with a computer than with their patients.
“The [registered nurses] are so busy doing paperwork that the DOJ has put up their yin yang,” said Christopher Dunn, a bristly Australian former psych tech and outward critic of the hospital when he worked at ASH.
At least one current psych tech said he’s been forced to write reports on group sessions even when no one shows up.
While the new, cushier models have been praised by those who created and mandated them, side effects have included increased assaults on staffers, increased patient-on-patient assaults, low staff morale, paranoia, and fear. Beneath the entire system is a philosophy that upended the way staff treated patients. No longer able to medicate agitated patients or put assaultive individuals in restraints while they calm down, staffers in California’s mental health system are effectively unable to treat using the methods they were taught for dealing with forensic patients.
“I’ve observed what’s happened over the years, and I think the primary reason that that place is so much more dangerous is because they’re not allowing doctors to prescribe medicine the way they should,” said one longtime employee. “And I’m not talking about chemical restraint.”
Before the new policies began taking shape at ASH, aggressive physical acts on staff rose modestly from 2001 to 2004. But in 2005, there were 373 attacks, roughly a 30 percent increase over the previous year. By 2009, the assault rates had climbed to 410, 118 of which required medical treatment and one of which required hospitalization. Fifty-three staff members had required medical treatment for their injuries this year, as of Oct. 6.
Among about 2,400 staffers, every ASH employee had a 17 percent chance of being assaulted in 2009, and that’s assuming all 2,400 of those staffers actually spent time behind the locked doors.
“Therefore, what DMH is doing for treatment with these violent offenders is not bloody well working,” Dunn said.
The move hasn’t been any better for patients, either—in fact, it’s worse. There were twice as many attacks in 2009 as in 2005, and nearly three times as many as there were in 2001.
More recently, ASH, along with other state hospitals, was forced to place the proverbial cherry on the cake of court mandates.
California hospitals recently began taking in an influx of patients who’d previously been backed up in the jail system. The so-called Mille decision—named for a patient who was found incompetent to stand trial and was supposed to be sent to a state hospital but instead was left to rot in a Los Angeles jail for 84 days—forced hospitals to take on such patients en masse, people who are inherently more violent and used to a prison/jail environment rather than a hospital.
Despite a bursting urge to speak up and speak out, many staffers are terrified to do so. Administrators are said to come down like the hand of God on anyone who causes trouble.
“The administration at ASH crushes anyone who believes in the First Amendment,” said one longtime employee who asked to go by the name Frodo as an homage to the Lord of the Rings, picturing himself as a little guy taking on Mordor.
Almost no current employees at ASH or other state hospitals contacted for this story were willing to be identified by name. Some wouldn’t even speak anonymously. One psych tech initially refused to give her personal phone number out of fear that an administrator or mouthy employee might question the caller ID if contacted from a New Times line. Frodo would only contact me by e-mail or from a payphone in case hospital administrators checked his phone records.
“Administration can make their life bloody misery at work,”
Dunn said.
But life can often be miserable without any administrative assistance. Though ASH’s violence has increased dramatically since 2005, other hospitals may have it worse, according to DMH records that were immediately available.
There was an average of 117 attacks on staff per month during the first six months of this year at Metropolitan State Hospital near L.A.—more in those months than the entire year of 2007. And patient fights this year grew by an average of 21 per month over the rate in 2006.
Patton State Hospital near San Bernardino had nearly as many staff attacks between January and June of this year as it had in all of 2007.
“There’s a physiological response that the body suffers during a time of crisis, and we have been told to ignore that,” Mark Cruz, a 31-year Patton psych tech, said of patients who show signs of aggression.
Napa had 410 attacks on staff and 1,348 attacks on patients in the first half of 2010.
“Now the situation has gotten so bad that staff are assaulted almost daily,” Frodo told me. “But it is all swept under the carpet by administrators who create dangerous policies and procedures, yet remain safe outside security.”
Million dollar baby
Roughly five years after first stepping foot in ASH, a team of court monitors has declared the hospital to be in “substantial compliance.” Great news, it seemed. Gold stars all around.
“We would like to acknowledge the arduous task undertaken by you and your colleagues to learn and implement the Enhancement Plan,” the DMH wrote to ASH staffers on Aug. 2. That month, there were 40 staff injuries resulting from attacks and 46 patient injuries.
Indeed, nearly every hospital the court monitors have assessed is in compliance, or almost there.
Headed by the Human Potential Consulting Group, which formed one month after the DOJ came in, the court monitors wrote their first report on ASH based on a four-day evaluation in late 2006. Led by Mohamed El-Sabaawi, the so-called “evaluation team” began compiling reports.
In that first year, El-Sabaawi’s group cashed in on a $925,100 contract with the DMH. A year later, the Human Potential got a four-year contract renewal, which landed it a grab bag worth about $1.04 million per year. The group’s business address is listed as El-Sabaawi’s home address in Alexandria, Virginia.
According to the Medical Board of California, El-Sabaawi let his license renewal slip and he was prohibited from practicing medicine in California as of February 2009. Officials from the DMH and DOJ have an answer for this: El-Sabaawi never practiced medicine in his court-monitor capacity and, “It is the responsibility of the Department and its Medical Directors, not the Court Monitor, to ensure that appropriate medical care is provided,” the DMH wrote in August 2009.
El-Sabaawi declined to comment for this story due to a court-issued gag order.
Over the course of five years, the group has amassed hundreds of pages’ worth of reports and critiques of the hospital. Still, some things have barely improved, and others have only gotten worse.
“The court monitors have come in and turned everything upside down,” Frodo said.
A survey of a small selection of ASH patients in 2006 found that 82 percent of them felt safe, but four years later the percentage bumped only slightly to 84.
The court monitors did report spikes in violence. From mid-2007 to early 2008, aggressive incidents between patients more than tripled, and the attacks on staffers more than doubled.
In response, monitors initiated a “Violence Abatement Project,” which came with more paperwork and stat tracking. However, attacks on staff reached a five-year high the following year, in 2009.
“There’s a lot more, an abundance of different types of procedures that require paperwork,” one psych tech told me. “It’s just increased astronomically.”
But many employees explained that despite the increase in paperwork, they know less about their patients than ever before. They’re allowed only limited information on patients’ criminal backgrounds and many complained that floor staff are generally oblivious as to which patients have been acting out.
More than a dozen staffers and union reps I spoke with worried that assaults might not be properly recorded and reported. They also complained that acuity levels—numbers that dictate staff-to-patient ratios in any given unit—are purposely lowered to make up for a lack of staff.
“They don’t always allow them, the nurses, to make their own judgment. They tell them, ‘Just lower their acuity,’” one psych tech said. “… On paper it looks like we’ve got enough staff.”
According to a staffing report provided by one employee, the staffing ratio on one unit was one staff to eight patients. Such a ratio is typically the minimum, according to other materials provided by the hospital. During the evening and night shift, however, no nurse was listed
on duty. On top of that, several employees worked nearly 20 hours of overtime combined, and several others were out sick.
Actually, a lot of people have been calling in sick at ASH. Often so exhausted by the mandatory overtime the hospital has implemented due to staff shortages, employees admit they use sick days as the only way to get a break.
“You have no fucking idea how difficult it is to work a 16-hour day, drive home, go to bed at 4:30, and then go back,” a former psych tech said.
Frodo, for example, was recently awake for 36 hours after working a day shift until the late afternoon, then returning that night for 10 hours of forced overtime, and coming back again for a regular shift the next day.
“This is a difficult place to work in the best of circumstances,” another psych tech said of the overtime.
And it’s not cheap. According to DeMorales, the executive director, the hospital is spending $850,000 per month in overtime.
In the last fiscal year, for example, ASH paid out $10.5 million for about 239,000 overtime hours. In the 2006-07 fiscal year, the hospital paid $13.4 million in overtime costs, according to DMH records.
Money continues to be a problem for the entire DMH. Over the past three fiscal years, the state has trimmed nearly $500 million out of the department’s now $3 billion budget.
“I have to tell you that the managing director at ASH is in agreement and equally frustrated at times about this,” said Chris Bricker, a representative with the local arm of the Service Employees International Union (SEIU) Local 1000. “But there again, we do have to face realities and if something is not coming forward in the big picture of what the situation is between the [court] mandates and actually executing them, and if all we’re doing is trying to pass muster every month and not trying to address all the acute problems that we have, then someone’s going to get hurt.”
‘I can’t help you’
Descriptions of the attacks on staffers and patients at ASH and other hospitals can make your blood curdle. Just as an FYI, “gassing” is when a patient fills a bag with urine, feces, and/or other bodily fluids as makeshift biological warfare.
“I’ve been chased, I’ve been gassed; I’ve had urine thrown at me,” said a Napa State Hospital employee who asked to go by the alias Sally Brown. “I have not been beaten up yet, and I say ‘yet’ because it’s going to happen.”
Former psych tech Dunn, for example, tore the ligaments in his fingers while wrestling with a patient. Another psych tech said he’s been punched in the face as well as hit in the face with a garbage can lid a patient threw at him.
A story in the January edition of the California Association of Psychiatric Technicians (CAPT) newsletter opens with the words, “Atascadero State Hospital Psychiatric Technician Ramona Goodman’s neck was broken when she struggled to escape a patient who was throttling her and sawing at her neck with a plastic knife.”
Goodman vividly remembers the patient. He’d been complaining that the voices were coming back, and he was acting out on other patients. But his doctor—a new recruit with little experience treating forensic patients, she said—mostly ignored the patient’s pleas for help and medication. At first, the doctor gave no medication, then jacked up the meds until the patient complained of being overmedicated, and then yanked him off it again.
And Goodman attributes the problems to the post-DOJ system that floods staff with busywork, leaving them almost no time to interact with patients.
“It’s almost like it inspires an environment that I’m so busy I can’t help you,” she told me. “I mean, it really pisses them off.”
One day the patient asked Goodman for some clean socks. She tried to talk with him on the way to the laundry room, and as she went to unlock the door, he wrapped his arm around her neck and mouth and she could feel something sharp on her neck. She couldn’t yell for help—she couldn’t even breathe—and she couldn’t pull the pin on the alarm pager all staff wear in case they’re in trouble.
Then he began hitting her in the side of the head.
“Finally I realized, I’m not going to win,” she told me.
If it weren’t for someone down the hall opening a door, causing the patient to instinctively drop to the floor rather than risk getting in trouble, she likely would have suffered much more.
After recovering, Goodman went back to work, and she kept at it for about six weeks. But physically and mentally, she just couldn’t do it anymore.
“Once you’ve been hit, going through security, it’s a hard thing to do,” she said.
There’s sadness in her voice. Goodman loved working at ASH, and she wishes she could return—but she can’t.
“It’s absolutely the best job in the world,” she said. “There’s no feeling like watching a guy coming back [to] reality.”
In the end, after being choked and beaten, Goodman doesn’t blame him—she blames herself, and she blames the hospital.
“And I feel horrible,” she said, “because I feel like we really failed this guy.”
Fighting back
On a brisk, sunny November morning, people garbed in matching purple shirts began to gather and hoist their signs in front of the DMH headquarters, an unmarked concrete and wood-paneled building that takes up a full square block in the southern portion of downtown Sacramento.
One sign read, “Violence epidemic, DMH cover-up.” Another read, “Stop the assault, stop the murder.”
“What do we want?” a man bellowed into a megaphone.
“Safety!” the protesters yelled back.
Protesters included Napa State Hospital employees, their friends and families, and representatives from SEIU Local 1000, which represents nurses at DMH hospitals.
One protester, a nurse of eight years, said she was assaulted by a patient who hadn’t been properly stabilized or medicated.
“And he pulled me into his room and strangled me,” she said.
A middle-aged psych tech in a pair of camo shorts and a ratty T-shirt rotated a toothpick in his mouth as he spoke.
“Everybody, if you work at Napa State Hospital, you’re going to be assaulted,” he said.
Next to him, a taller man in jeans and a white T-shirt twirled a cigarette in his fingers. He said he’s been punched in the face by a patient, and he was recently attacked again. He slid the sleeve on his right arm and showed the bruises on his shoulder.
“We all got little marks on us,” he said.
The man with the toothpick pulled up the shorts on his right leg and showed his knee, scarred and swollen to about twice the size of his other one. He said the hospital is severely lacking in security, and its ability to provide treatment has been neutered to the point where medicating a patient to calm him down requires so much paperwork and leaves the staffer so vulnerable to being labeled abusive, he doesn’t bother trying anymore.
“Your state government is giving them vitamins and that’s it,” he said. “… It’s getting progressively worse, and it’s not getting better. It’s to the point that we’re getting killed. Until this point, we were just getting beat up.”
On Oct. 24, Donna Gross was murdered, allegedly by a Napa patient. A 54-year-old psych tech from Concord, Gross was the first staff member to be killed since a 1990 murder at ASH. Her alleged killer, 37-year-old Jess Willard Massey, has been charged with murder and second-degree robbery. In fact, Massey, who had a history of violence against women, was transferred to Napa from ASH at the request of staff, according to the San Jose Mercury News.
Two weeks before Gross was murdered, Napa employees circulated a petition in response to the increasing violence, according to one of Gross’ coworkers and an organizer of the Facebook protest group CaStaff Legislation, which formed to pass legislation and enhance hospital security. The group has more than 1,000 followers.
“We need all the help we can get, we really do,” said Sally Brown. “We need to expose the state. It’s a big abscess that just continues to ooze.”
Members have contacted Assemblywoman and soon-to-be Napa State Sen. Noreen Evans and Assemblyman-elect Michael Allen. San Luis Obispo Sen. Sam Blakeslee carried several pieces of legislation to help protect workers at ASH, but the more aggressive aspects were cleaved and stalled by committees, he said. Blakeslee was able to pass three bills: a tobacco ban in state hospitals, a bill that allows employees to donate vacation and sick time to other employees, and one that required annual reporting on worker safety issues for three years.
“This does need to get out there,” said Brady Oppenheim, a spokeswoman for the union that represents psych techs. “Something needs to happen to protect our members and the people they care for.”
On the day of the protest, a delegation of hospital employees and union reps met with DMH administrators. Even DMH Director Steven Mayberg attended the meeting briefly, surprising some who thought he would hide from the protesters that day. But according to Rosa Sanchez, a nurse practitioner at Napa who sat in on the meeting, the message didn’t get through.
“We do not believe that our issues are going to be addressed,” she told me after the protest wound down. “So that’s why we are thinking of the next levels.”
Such a response isn’t all that surprising considering the types of answers that can come out of DMH.
“The safety and security of staff, patients, and the public has always been one of the highest priorities for the Department,” Mayberg said in a prepared response. “There are a number of factors that must be considered when looking at aggression trends, which we constantly monitor and address. We remain committed to the ongoing analysis of aggression-related issues and will make modifications to policies and processes system-wide as needed to enhance the safety and security of our facilities.”
Jennifer Turner, a young public information officer who speaks like a human press release, said DMH is aware of the concerns, is taking them into consideration, and is of course concerned about safety.
“The department does not take the concerns of safety and security lightly,” she said.
What about the DOJ’s influence? Or the increasing assault rates? Or employee concerns that the problems are being swept away? Turner insisted that the assault rates weren’t increasing, but the seemingly higher numbers are a reflection of how the department has changed its tracking methodology and a changing population of patients. As for the DOJ and the Enhancement Plan, she said it is “definitely a factor that we’re looking at.”
Responding to similar questions, a DOJ spokesman said, “The consent judgment requires the state to provide adequate treatment and adequate protections from harm; and we haven’t seen any data indicating that the consent judgment’s implementation has caused an increase in aggression at any facility.”
ASH Executive Director DeMorales balked at the notion that either the Enhancement Plan or the Wellness and Recovery Program have anything to do with increasing violence at ASH. Sure, there are some things he disagrees with, but “I think the Enhancement Plan has become a whipping boy for some staff.”
“It’s really difficult to implement change of any kind, much less major change like the treatment planning process in a state facility that’s so heavily unionized … and I think it’s human nature to resist change, but there’s got to be an opportunity,” DeMorales said.
He discounted much of the criticism outlined by staff, saying that a lot of it comes from small groups of relatively new employees without the historical knowledge to justify their claims. And the real issues can be directly attributed to changes in the patient population that occurred at the same time as the DOJ’s interference, as well as state budget cuts and employees calling in sick, which has upped the need for mandatory overtime, he said.
“It’s a vicious cycle that hurts everyone,” he said.
DeMorales admitted that ASH has suffered more assaults in recent years, but the hospital is turning patients out as fast as it’s taking them in. In other words, ASH is rehabilitating its population and shipping them out, leaving the hospital with a high volume of new patients who tend to be more aggressive during their first 90 days.
“Even though the aggression rate is really high—and it corresponds to the rate of admissions, which is really high—the rate of serious injuries … has not really increased accordingly,” he said. “That tells me that the staff are very effective in terms of their interventions.”
If people like DeMorales and Turner are right, it could mean all the people I talked to—psych techs and nurses, union reps, and their families—are haplessly seeking to assign blame where there is none. But if the leaders are wrong, it means the problems will continue—staff will continue to be assaulted without consequence, and perhaps, someone else will die. In the end, no one will win.
“The problem is not the patients,” said SEIU rep Daniel Solnit. “The problem is not the people who advocate for good treatment of patients. The problem is management that just don’t give a damn about their workers, about their safety, about their lives.”
The thing to remember is patients in a place like ASH may not be model citizens, but they’re severely mentally ill and in need of real help—something employees worry they can no longer provide. Goodman spoke of a man sitting on a curb eating his sandwich. Nearby a woman walks to an ATM, which the man thinks is trying to steal her soul. So he puts his sandwich down, walks over, and stabs her to death, thinking he’s saved her. Then he goes back and finishes his sandwich.
“We need to get things there back on track,” Frodo said. “We’re not doing society a service, we’re not doing staff a service, and we’re not doing these patients a service.”
News Editor Colin Rigley can be reached at crigley@newtimesslo.com.
This article appears in Dec 2-9, 2010.