What's troubling the staff of the Vermont State Hospital?
The Brooks Building is a remarkably dark and grim place, considering all the light that's shone on it lately. Home to the Vermont State Hospital, Brooks is the last building on the state campus in Waterbury that still houses psychiatric patients. We wind through a labyrinth of hallways and basement tunnels as dank and confining as catacombs to get to Brooks One Unit, the highest security psychiatric ward in the state. When we finally emerge, our guide, Nursing Administrator Anne Jerman, unlocks a heavy iron gate. As we enter the unit, she warns the photographer and me to be alert to our surroundings and keep a tight grip on our cameras and other personal items. "Just be aware that they can be used as a weapon," she says.
Brooks One is home to 20 of the state's most complex, intractable and dangerous psychiatric patients: severe schizophrenics and paranoids, dementia patients too violent to be cared for in nursing homes, people found not guilty by reason of insanity or ruled mentally incompetent to stand trial and others who are at severe risk of harming themselves and others.
Jerman's dead-serious warning -- that my ballpoint pen could be used as a weapon -- is meant literally, but it could just as easily have another meaning. On November 30, the hospital regained the federal certification it lost a year ago after a series of surprise inspections turned up a host of deficiencies, and two patients committed suicide. In a workplace where getting a broken nose or a kick in the groin is always a risk, the hospital staff isn't looking for another black eye from the press.
As Jerman walks us through the unit, several patients -- or "clients," as the staff call them -- eye their visitors warily and shuffle around in shoes with the laces removed. Patients in Brooks One aren't allowed to wear shoelaces, belts, drawstrings or anything else that could be used to strangle someone or to hang themselves. The visual effect of this ubiquitous fashion statement -- sneakers with their tongues sticking out -- is arresting.
Outside the barred windows, loops of razor wire are visible atop the chain-link fence that secures the unit's outdoor exercise yard. Most urban dog runs provide more space than this narrow ribbon of frozen dirt. Not that the patients assigned to Brooks One get out much in the winter, anyway. Psych Technician Dale Spaulding, who's worked at the hospital for 29 years, says he notices a difference in the summer when the patients can go outside. They're much less agitated, he says, and less likely to injure the staff or each other.
But even when the weather allows for taking patients outdoors, oftentimes there aren't enough employees to supervise those who are inside and out. Other times, the supply of winter coats falls short. To compensate, nurses and psychiatric technicians say they occasionally bring their patients clothes from home. Others buy them socks and underwear when they can't acquire them through the state. Many say they spend their own money buying equipment and office supplies, too.
At this time of year, fresh air inside the unit is also an issue. When we arrive, most of the patients are taking their morning cigarette break on an outdoor balcony -- an enclosed cage with a depressing view of the exercise yard and parking lot. Apparently, the calming effect of nicotine trumps other health considerations. Several times a day, secondhand smoke wafts through the halls. The ventilation in this century-old building doesn't improve the air quality. And it's not as if the staff can just open a window.
Jerman unlocks the door leading into "The Bubble" -- a Plexiglas-enclosed employees' station in the center of the floor. On the corner of a desk, a small, black-and-white TV monitor cycles through the various closed-circuit cameras positioned throughout the ward. While most of the patients are outside having a smoke, the staff pore over piles of paperwork. As part of the corrective plan for recertification, the hospital completely overhauled its system for documenting patient treatment and care.
The staff say that more documentation is in general a good thing, but it didn't make their already stressful jobs any easier. "At first it seemed like we were getting new documents every day, if not four or five," notes Kate Plummer, a nurse who works upstairs in Brooks Two, a lower-security unit. "They changed every single piece of paper we used, plus gave us 100 more. What they wanted was not necessarily for more to be done, but for more to be written down."
Shift leader Jeni Roggensack, who's worked as a psych tech at VSH since 1987, agrees. "They gave us 50 percent more to do but never gave us more staff to do it," she says. "The thing is, the care of the clients has never changed. They've always been number one. I don't think the community sees that."
In the tight quarters of the Bubble, nurses, doctors, and psych techs move around one another in a familiar choreography. When a patch of desk space opens up, someone immediately occupies it with a folder, three-ring binder or patient's chart. Meanwhile, on the outside of the glass, the patients watch the activity inside with mild curiosity or medicated detachment. It's not entirely clear who's observing whom.
In the last 18 months, the employees of the Vermont State Hospital have had more than their share of eyes watching them -- federal health-care inspectors, investigators from the U.S. Justice Department, state lawmakers, commissioners, advocacy groups, the media. Yet few have looked at the place from the employees' point of view.
The hospital first came under the magnifying glass in the spring of 2003, when investigators from the Centers for Medicare and Medicaid Services paid a surprise visit to the 54-bed facility. They turned up 29 deficiencies, including faulty equipment, chronic staff shortages, inadequate patient documentation and a failure to engage clients in ongoing treatment. One finding that drew widespread criticism was the charge that patients were routinely locked in their bedrooms at night, some without access to bathrooms.
But according to Erika Martin, a VSH nursing coordinator who testified to the legislature's Mental Health Oversight Committee last week, locking patients in their rooms at night wasn't a new practice. Some staff claim that the patients preferred the security it afforded them. "We'd been through numerous inspections over the years and it had never been an issue," says Martin. "Suddenly, we were getting cited for it."
Then on August 8, 2003, VSH patient Christopher Fitzgerald, a 39-year-old mechanic from Fairfax, hanged himself in his room with a piece of nylon string. According to the investigation by Vermont Protection and Advocacy (VPA), the federally funded nonprofit group that advocates for the rights of the disabled and mentally ill, Fitzgerald suffered from depression, possible alcohol abuse, Borderline Personality Disorder and suicidal tendencies. Shortly before his death, hospital staff had to restrain Fitzgerald during a violent episode.
Only weeks later, on September 15, 2003, another patient was found dead. Nineteen-year-old Amanda Menei had had a long and troubled history of psychiatric problems, including hearing internal voices that told her to kill herself. Having suffered severe sexual abuse as a child, she'd been diagnosed with Post-Traumatic Stress Disorder, severe depression, Borderline Personality Disorder and multiple substance abuse. At the time of her death, Menei had been admitted to the Vermont State Hospital for the sixth time in 18 months. Hospital staff found her hanging by a shoelace in a locked bathroom.
The VPA came down hard on hospital personnel. In the Fitzgerald case, VPA concluded that hospital employees had used "an unnecessary show of force" when restraining him, which likely exacerbated his already agitated condition and suicidal tendencies, and may have directly contributed to his death.
In the Menei case, VPA concluded that, among other things, hospital employees hadn't adequately communicated the nature and severity of her condition to other staff members when she was transferred to another unit. VPA also concluded that the ward was poorly staffed at the time of her death. But the physical layout of the ward also played a role -- the nurses and psych techs on duty at the time couldn't see her on the video cameras. VPA concluded in both investigations that the suicides could have been prevented.
Within weeks, the hospital was stripped of its federal certification, losing about $2.8 million in federal funding. Suddenly, this dark institution was in the limelight, and it wasn't flattering.
Those who work in the mental-health profession understand the therapeutic value of airing troubles. Still, there's been very little soul-searching done in public by the staff of the Vermont State Hospital. Through much of last year's turmoil, the hospital's rank and file remained largely silent and unseen in the press. Partly, that's the nature of their professions. Breaches of confidentiality in a mental institution carry serious legal and ethical consequences. Some hospital employees admit that they were reluctant to speak publicly, fearing retribution from administrators or other staff. But others say that with all the media attention focused on the hospital's shortcomings, no one ever asked to hear their side of the story.
"Mental institutions have always been these weird, mysterious places, and everybody wants to write 'the big story' that exposes all the wrongdoings that occur there," says nurse Kate Plummer. "Meanwhile, we've all been coming to work every day and actually doing the work that nobody sees, and are not allowed to see. It's one of those things that you can never get recognition for because nobody knows what it's like."
Some VSH employees suggest that the decertification process confirmed what they'd been saying for years: that the hospital is woefully understaffed and underfunded. "Partly, we felt almost relieved when we got decertified because the state didn't have a choice anymore," says nursing coordinator Martin. "If they wanted to get the money back, they had to start giving us the resources we need in order to survive as a hospital."
But the decertification was also, as Martin put it, "a real slap in the face" to the staff, especially those who have been there for years. Many of them, and their families, were working at the Vermont State Hospital when it was a center of excellence, an institution to which the World Health Organization and National Institute of Mental Health would send researchers to study successful rehabilitation techniques.
"It's not unusual for people to tear up when they talk about the state hospital," says Terry Rowe, who came aboard as the facility's executive director in June. "I think that decertification for some, if not many, of the staff equaled a lack of validity as a competent staff group, that there was something really shameful about it, and that this was a blot on the character of an institution that people have an intense loyalty to."
No one working there now denies that the place had serious deficiencies that needed to be corrected -- and still does. Employees and administrators alike refer to the hospital as "a dim, grim place," "the forgotten stepchild" and "a dungeon." But what bothers them is the perception that the fault lies with the employees themselves, rather than years of systematic neglect on the part of the state.
"Obviously, we were lacking in many areas. We were seriously understaffed," says Martin. "But a lot of people knew they were doing the best they could with the resources that they were provided with. People were giving good patient care. And staff really, really care for their patients.
"But no one was sticking up for what the staff were going through," she adds. "The staff were looked at as these horrible, nasty, abusive people who were locking patients in their rooms and not letting them out to go to the bathroom, when in actuality, many of those rooms have bathrooms in them. You didn't hear that."
Other VSH employees note that most of the public has no idea how physically and emotionally demanding it is to care for Vermont's most acute psychiatric patients -- or how dangerous. VSH employees suffer the highest rates of injury of any group of state employees, including prison guards. Nevertheless, the concern they feel for their clients is readily apparent.
Recently, a staff member was attacked and seriously injured by a patient. Rowe was on the floor at the time and, unbeknownst to her staff, watched on a video monitor as the patient was escorted away.
"What I was really quite moved by was the tenderness that the staff exhibited toward this patient," says Rowe. "They were able to really understand that the patient's behavior was simply behavior, not an indicator of who this person was or his value or worth... and still have compassion for him. That's what people also need to know about the staff at the Vermont State Hospital."
That concern is evident, as well, when they speak about last year's suicides. Reportedly, a lot of grieving went on among the staff. Rowe says that her people feel a deep professional obligation to keep their clients safe -- and some still wonder what they could have done differently.
"You can work 24/7 and hopefully give your clients the skills they need to want to be in their life," says shift-leader Roggensack. "But you can't always do it. You're going to fail somewhere. And it wasn't from lack of trying. But when the suicides happened, it was, 'Vermont State Hospital -- look how bad they're doing. They did this, they did that.' But they didn't look back at all the years of successful treatments of people who were suicidal but were able to go home."
"Or count how many times we took something off the neck of the lady who hanged herself," adds Trish Stewart, a registered nurse who works alongside Roggensack. "There were so many times that we intervened and were able to save her. And then, once, we weren't."
Interestingly, when VSH employees talk about what's lacking at the Vermont State Hospital, they don't often ask for improvements that would benefit them. Nor do they complain about their modest salaries. While nurses' salaries were beefed up a bit this year, VSH staff are still among the lowest-paid state employees. The starting wage for a psychiatric technician is $12.59 per hour.
What's more, their work offers few opportunities for public acknowledgment. The rewards of their jobs are few and far between, and might seem trivial to outsiders. "They are little things, like having a paranoid person say that they trust you," says Stewart. "Or having somebody whose affect is really flat, and her responses really canned, come out with an emphatic 'Thank you!'"
"I have a client who has been in and out of here throughout the years, and when she's having problems, she'll call me at work and we'll have a 15- or 20-minute conversation," says Roggensack. "And she feels good about it and we won't see her. But she trusts me enough to call and lay her stuff on the table."
When mental hospital employees testified last week before the Legislature's Mental Health Oversight Committee, their requests for capital improvements were modest, considering all that's lacking in their workplace: an employee lounge where the staff can decompress instead of going to their cars; dimmer switches for the patients' bedrooms; comfortable chairs for the patients' lounges; treatment for the persistent mold problem that plagues the bathrooms and hallways; a private area for patients to meet with their families or lawyers; and something to muffle the clanging of steel doors when they slam shut.
"How long has it been since we've been talking about a soundproof seclusion room?" asks Stewart. "I can't even imagine why a mental hospital doesn't have one, because everyone knows how influenced these people are by noise. So, if you have somebody who's in a room yelling and pounding, it just reverberates through the whole ward."
In the coming months, the Legislature and other stakeholders will continue to debate how psychiatric care will be delivered in 21st-century Vermont. The particulars of the "Futures Project" have yet to be finalized. Still up in the air, for example, is whether the entire state will be served by one facility or several smaller, regional centers, or who will run it -- the state, a nonprofit agency or a private contractor.
And though the recent recertification ends a long and painful chapter, another one could begin soon. The Justice Department is currently investigating possible civil-rights violations.
What's clear is that within three to five years the current facility will be closed, ending an institution in Waterbury that dates back to 1891. When that happens, the Vermont State Hospital staff hope no one overlooks the seriousness of their commitment.