Too much attention is paid to violence perpetuated by persons with mental illness and the associated solutions that focus on control and coercion. I'm writing in response to Steven Seager's op-ed titled "Where Hell is Other Patients" that was published in the New York Times on Nov. 10, 2014. Seager argues that violence against staff members and other patients is due to "untreated psychotic patients" having too much freedom. He blames the legal system for not requiring court-ordered treatment (e.g., medications) and he blames hospitals for not providing trained security guards or special units to separate patients from each other. Nowhere in the piece does he call for better care, more nursing staff, or any process or model that can be effective in creating safe treatment environments. He simply calls for control, coercion and isolation.
For decades, violence on inpatient psychiatric units and violence and psychosis have been topics of discussion reflected and perpetuated by their inclusion in film. The themes of control and coercion on inpatient psychiatric units is evident in films such as One Flew Over the Cuckoos Nest (1975), Girl, Interrupted (1999), and Changeling (2008).
I offer firsthand experience as a psychiatric mental health nurse and mental health researcher, and I'd like to provide an alternative perspective to the control and coercion model. As a member of the American Psychiatric Nurses Association's steering committee for the Institute for Safe Environments, I've had many conversations with experts around the country, and I've thought about this issue a lot. As a psychiatric mental health nurse for over 30 years who has worked on numerous inpatient units, and through my research on treatment environments, therapeutic relationships and nurse-patient relationships, I maintain that there are other options, namely recovery and trauma informed care models that focus on hope and interpersonal engagement.
Studies support this. Nurse researchers from Yale University studied factors that relate to violence on inpatient psychiatric units and found that violence can be decreased by a culture or environment where nurses actively engage interpersonally with patients and collaborate with them on their treatment planning.
This and other studies show the benefit of providing care within a trauma informed care model, not only with fewer incidents of violence, but with better patient outcomes, and increased patient and nurse satisfaction. Trauma informed care environments are guided by six key principles: safety, trustworthiness and transparency, peer support, collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. [A full description of the model and specific interventions can be found on the Substance Abuse and Mental Health Services Administration's National Center for Trauma Informed Care.] None of these principles seem evident where Seager works, nor does it show up in his potential solutions.
To be sure Seager's focus was on persons who are on forensic units and have been found guilty by reason of insanity, or what might be called "guilty but insane" in other states. Nurses and other health care providers in these environments are themselves sometimes traumatized by the work that they do or through their daily interactions with traumatized persons, which can cause vicarious traumatization in these health care providers. It's true that patients in forensic settings may require different treatment models but they should be offered the most evidence-based care available, and those are based in recovery and trauma informed care principles.
Inpatient psychiatric care has made great strides against controlling and coercive care environments in recent years. One clear example of this relates to overall fewer incidents of seclusion and restraint, which should be applauded, but that also doesn't go far enough. Eventually treatment environments should become seclusion and restraint free. But we've got so much further to go.
We as a society, and for those of us who are mental health care practitioners in particular, need to examine inpatient psychiatric and forensic nursing care and create safe(r) environments. We need to engage persons with mental illness, not further traumatize by focusing on isolation, control, and coercion. We need to create systems and environments that help persons focus on recovery from mental illness (and the stigma that it causes), and systems of care that are trauma informed, not trauma inducing.