Security and patient management in a forensic hospital

Emphasizing the use of humane techniques and interventions, the security model discussed here has proven more effective, more therapeutic, and more economical than traditional approaches.

Security and Patient Management in a Forensic Hospital Ronald Woodson

The need for security in a forensic hospital is determined by the type and nature of the patients referred. The majority of the patients in this setting are channeled through the criminal courts, which means many of the patients have serious criminal charges pending or have been found not guilty by reason of insanity relative to various and frequently violent offenses. As a result, security must be maintained to prevent escapes, assaults, and self-injurious behavior from occurring. As a treatment facility, security must allow for the need for a therapeutic environment while resisting the tendency toward a security- dominated environment.

Historically, approaches to security in forensic facilities have emphasized the recruitment of physically imposing, no-nonsense staff and liberal use of take-downs, handcuffs, belly chains, strait jackets, locked isolation rooms and other types of intimidation techniques or interventions. The primary objective of such approaches was the immediate physical and psychological control of patients who got out of line. These approaches maintained security in the strictest sense of the word but proved costly and largely ineffective because they did little in the way of addressing the issues underlying patient3 problematic behaviors and, in fact, would frequently exacerbate rather than defuse such behaviors.

The challenge for security administrators in forensic facilities is to develop and implement security models that achieve an environment as free as possi- ble from risk and danger while simultaneously emphasizing an approach to patient management that is humane, therapeutic, and fiscally feasible. As security administrator of the Michigan Department of Mental Healths Center for

NEW DIRECTIONS FOR MENTAL HEALTH SERWCES, no. 69, Spring 1996 8 Jossey-Bass Publishers 35

36 EMERGING ISSUES IN FORENSIC PSYCHIATRY

Forensic Psychiatry (CFP), I have experimented with the use of a model drawn from the works of kce (kce, Hams, Varney and Quinsey, 1989).

The model contained what Rice considered to be six key and readily identifiable characteristics. Those characteristics include static physical controls, dynamic physical controls, pharmacological controls, situational controls, interpersonal controls, and self-control methods. In the application of the model at the CFP, emphasis was placed on interpersonal and self-control techniques. The model and the results of its application are discussed below. No scientific study or formal data collection process was developed to analyze and formu- late the conclusions. The results were based on observations of the nature and types of problems I managed as security administrator.

Static Physical Controls The first area for consideration is identified as static physical controls. The term static in this application carries the meaning of that which is permanent and structural in nature. Environmental design items such as window screens, chain link fencing, barbed wire, doors and locks, seclusion rooms, unbreakable glass, and electronic monitoring systems come under this category. The application of this type of security provides both advantages and disadvantages.

The most obvious advantage of using static physical controls is deterrence. Even though some psychatric patients are not able to assist in their own defense, many are lucid enough to recognize the futility of running through locked doors or climbing over fences with barbed wire. Being able to contain or control the movement of individuals based upon environmental design assists in the main- tenance of security Deterrence is not only a formidable feature-more importantly a delay factor is introduced. This delay factor is commensurate with the degree of difficulty it takes to breach a security barrier. The noise and preoccu- pation with trylng to breech the barriers will invariably delay the patient. This delay will allow the hospital staff to receive an early warning that a barrier is being compromised and therefore provide staff time to intervene.

The most prevalent disadvantage is complacency Staff of forensic hospi- tals may place too much emphasis on hardware and environmental design to solve what are essentially people problems. Locked doors, panic alarms, and strong fences do serve a beneficial purpose-but they do not stop the critical issues of patient-to-patient or patient-to-staff assaults. For example, federal government studies report that with the increase in hardware in federal institutions there was a proportional increase in violence (Porporino and Marton, 1983). Environmental designs and structural barriers do not solve all security problems.

At the CFP, we do rely heavily on static physical controls. For example, consider our history with escapes. The installation of a twelve-foot-high chain link fence with a motion detection system clearly testifies to the effect such controls can have on patient behavior. There were several successful escapes prior to the installation of the fence and motion detection system. However,

SECURITY AND PATIENT MANAGEMENT IN A FORENSIC HOSPITAL 37

postinstallation escapes are zero to date. Although several attempts were made to breach the fence, none was successful-due largely to the early warning system provided by the motion detection system and quick response of attend- ing staff.

We have installed panic alarms in high-risk areas, and triggering these alarms immediately dispatches a number of emergency staff to the site of the alarm. We have noted that some staff are quick to activate the panic alarm system, even when there is no serious security threat. The staff person usually has not adequately discussed the situation in terms of less intrusive deescalation techniques but was invested in showing a demonstration of power, reaf- firming to the patient who is in control. In most cases the incident could have easily been diffused with proper verbal and nonverbal deescalation techniques rather than relying on a response from the hospital emergency response team (Lalemand, 1989).

Dynamic Physical Controls The second category is identified as dynamic physical controls. This control is described as dynamic because of its temporary and modifiable nature. Appli- cations in this category may include physically holding a patient or the use of a variety of restraint devices.

One of the major advantages with using dynamic physical controls is that they are temporary and selective in nature. Generally application will only affect the patient involved and provide for some freedom of movement rather than affecting a group of patients and drastically limiting freedoms.

The disadvantage of this form of security application is that it requires staff to actually physically manage a patient. Any time physical management is involved, it is usually applied to a unwilling and uncooperative patient. Patient and staff injuries may occur during this process. Also, the application of restraints-whether plastic, metal, or leather-must be done under the super- vision of a physician. This means that restraints cannot be applied to a patient without the verbal or written directive of a physician. After the directive is given the physician is required to physically inspect the patient within eight hours of the restraint order. This will ensure that no adverse condition occurs as a result of the restraints or triggers some predisposed medical problem for the patient. This form of security must be used judiciously because of the legal and medical ramifications of misuse.

It has been my experience that the application of dynamic controls has been used with a large measure of success at the CFE The use of restraints in various forms has benefitted the patient in several ways. Overreliance on seclusion-justifiably viewed by protection advocacy groups as a restrictive and aversive form of treatment-has dropped over the years. As a result, patients are integrated among their peers much faster and may participate in some unit activities. The use of dynamic controls, principally in the form of restraints, has been modified with time and experience to meet the specific problems of


our patient population. This modification has taken the form of wrist or ankle restraints (or both), or modifylng a chair and attaching wheels and restraints to it. This will secure the patient to the chair so that the patient can be on the unit and maintain some ambulation. The unit provides a more varied environment for the patient rather than a state of sensory deprivation (seclusion), which is undesirable for a patient who is already psychologically traumatized by placement in a maximum security facility. Patients generally are cooperative and become much more invested in plans of service if they are able to stay out of seclusion. Clinical team cooperation is also improved by decreasing seclusion, which most clinicians find undesirable, but which was the preferred form of control by psychologically unsophisticated security staff. Finally, a reduction in patient and staff injuries has been noted as a result of using this form of treatment rather than wrestling a combative patient to seclusion.

Pharmacological Controls

The third mechanism employed as a indirect form of security is pharmacological control. A word of caution is to be mentioned with this particular category. Psychotropic or any other medication should not be used purely as a security tool. Its primary and intended purpose is for the treatment of psychiatric symptomatology However, serendipitous benefits of psychotropic medications in a forensic hospital cannot be ignored. The value of drug therapy to reduce aggressive and self-destructive behaviors has impacted significantly on providing an environment free from risk and danger to patients and staff. As importantly, besides the clear therapeutic benefits, in some cases pharmacology is actually safer and can be cheaper than the application of environmental or dynamic controls.

As a security administrator, one of the biggest problems I have noted with this form of application is that it can be easily viewed by some staff as a panacea for aggressive, assaultive, and self-destructive behaviors. Unfortunately, when too much emphasis is placed on psychotropic medications, it is done at the expense of other forms of therapy and interventions. Also, a negative consequence of psychotropic medications is the lethargic behavior associated with administering the medication. In this particular state, it is difficult to get the patient involved in any meaningful activities or therapies. Therefore, psychotropic medications must be used judiciously and carefully monitored.

Situational Controls

The fourth mechanism used for security purposes is situational control. A situational control is the identification and selection of specific prescribed envi- ronments in which a patient is allowed to function with restrictions of movement. A patient with a history of suicidal or homicidal behavior would not automatically be allowed to enter an area or participate in higher functioning activities where items could easily be used to carry out dangerous or


self-injurious behavior. On occasions when patients on the same unit are in repeated altercations situational controls can be used to address the problem. One or both of the patients may be transferred to different units.

This particular control mechanism leaves some responsibility for self- management with the patient. Through the treatment team process this control mechanism can be specifically tailored to meet the needs of the patient involved. Because of the variation this approach offers the patient, he or she can only qualify for greater privileges by exhibiting stable cooperative behavior.

The biggest security problem I have noted arises when there is an inconsistent application of the plan of service that the patient must follow to receive greater liberties. Sometimes factors other than those specifically in the interest of the patient can have a dominating influence in the development of the plan of service. As a consequence, the patient then views the plan of service as a form of punishment rather than as a supporting mechanism that allows the achievement of greater freedom. In order to counteract this, the treatment team must perform at an optimal level in order to present a unified approach and implement a workable solution to the patient’s problems. The application of the elements of the plan of service must be applied equitably and consis- tently by all unit management staff. Some of the more higher-functioning, sociopathic personalties have been known to take advantage of the disunity and inconsistent application of plans of service to divide the staff. When the treatment team becomes dysfunctional and the application of the plan of service is inconsistently applied, the disruption of a safe and secure environment is sure to follow.

Interpersonal Controls The fifth control mechanism is interpersonal control. This mechanism relies heavily on staff interacting with patients and using defusing techniques and verbal skills to address and manage problematic behaviors. Research clearly shows that this form of control is very effective in that it leads to fewer violent incidents in a psychiatric setting (Wener, Frazier, and Farbstein, 1987).

At the CFP, we use an activities program to achieve a high level of interaction between security staff and patients. This program is independent of and complements the hospital’s regular activities program. On the units, the assigned security staff are required to develop and initiate activity programs so as to involve patients. This approach has had a positive impact on patient-to- staff relationships. The patients no longer view staff just as turnkeys or guards, but rather as individuals, and staff begin to view patients as more human. When this transformation occurs, half the battle of providing a safe and secure environment is well on its way. This interaction reduces the likelihood that a staff person will be viewed merely as an inanimate object or obstacle to freedom. Patients are more likely to be responsive to the directions of staff mem- bers who spend time interacting with them. On numerous occasions, patients have come to aid of favorite staff and even warned them of some impending


danger. The activities program eliminates the extra risk factor forensic staff experience when they become dehumanized to the patients.

Also of particular interest is the decrease in the number of seclusion, restraint, and one-to-one hours used when compared with the increase of activity hours spent by staff engaged with the patients. We believe the high level of activity programming by forensic staff results in less of a tendency on the part of patients and staff to dehumanize each other and is directly related to the decrease in the number of hours individual patients spent in seclusion and restraints.

One problem with this approach is a reluctance by some to participate and encourage patient participation in the various activities. When staff have a myopic view of their role, regarding their job description as security only, then the creation of any meaningful relationships with patients will not occur. In addition, the relationship created through close association has on occasion caused some staff to become less than professional in their relationship with the patients and to violate boundaries. It is here where security is most likely to be compromised because of an overly sympathetic staff person who feels that the patient deserves more than the system allows. Such staff persons may begin to do special favors for the patient, such as provide food, money, ciga- rettes, and even illicit drugs. However, despite the negatives, with enhanced training, this approach is highly effective and can serve as a catalyst for a safe and secure environment.

Self-Control The sixth area for discussion is the achievement of security through patient self- control. This is clearly the hallmark of good institutional security. In this area, security is achieved from the greatest source of danger-the patient. Getting patients to regulate their own behavior will do much to prevent or minimize violence. The five categories previously mentioned all require someone else to make a decision regarding patient behavior. Self-control requires patients to determine the extent and scope of their behavior and exercise choices. Addi- tionally, the other areas achieve maximum benefit or are only effective whle the patient is in the forensic environment. The benefits of getting a patient to use self-control are long-lasting and the skills learned or developed can be taken with the patient and used when needed.

Generally, through self-control techniques, the patient is taught to recognize behavioral and thinking patterns that precipitate undesirable behavior. Once this behavior is identified, the patient is than taught acceptable ways of redirecting or refocusing on positive outcomes to the behavior. Often, the patient is helped to recognize undesirable behavior through psychotherapy By means of the plan of service positive behavior is rewarded and reinforced by the unit staff.

Of course, the disadvantage of this technique would occur if the patient failed to recognize the need to regulate behavior. Also complicating the appli-


cation of self-control would be the patient’s inability to manage behavior due to mental illness.

At CFP, we believe that most patients are eager to take charge of their lives and prevent the circumstances that gave rise to their current situation. By actively working with the clinical team in developing a plan of service, patients become vested in a course of socially acceptable behaviors that will ultimately provide them a way out of their legal situation and importantly minimize the likelihood of a relapse and subsequent return to a restricted situation. This method allows for a fine-tuned approach in addressing the particular needs of the patient. For individuals who have never demonstrated any control or focus in their lives, the techniques and skills acquired through this approach serve as a benchmark of reintegration into society

Another benefit I have noted in pursuing this method of self control is that staff become much more sensitive to the needs of the patient and become actively involved in the patient’s overall progress. This reduces the likelihood of staff feeling that they do not have any meaningful input in the clinical team process, a tendency that can serve as a negative influence on the therapeutic milieu if not managed properly. When all staff are part of the clinical team process of developing specialized plans of service for the patients, staff apathy is reduced, and this in turn produces a much more therapeutic environment.

Conclusion At CFP, we have found that the kce model serves as a good framework for bal- ancing and achieving security in a forensic hospital. However, although Rice captured some readily identifiable methods for patient management, these methods do not represent other variables that impact on security For example, the gender mix of the security staff makes a difference (Petersen, 1982, p. 437). Prior to the integration of women security staff on the units, the tendency for acts of aggression by male patients towards male staff was much higher. There has been a considerable drop in the display of aggressive behavior by the male patients since we integrated female security staff on our male units. This is a factor that should be given serious attention when considering security in male-dominated situations. Also, the number of staff available for the units is another factor that deserves paramount consideration. The mere presence of sufficient staff to address aggressive behavior has been known to serve as an added reinforcement to both patient and staff that the environment is safe and secure.

It seems imperative that security administrators look to the integration of various methods and services to develop a good security system. No single department or service can provide complete security Rather, it is human interaction responding to the needs of another human with the aid of technology, science, and a great deal of teamwork. The overall thrust of security through the model presented produced a much kinder, more efficient, and more economical approach to achieving a balanced, safe, and secure environment.


References Lalemand, K. Non-Abusive Physical and Psychological Intervention: Participant’s Manual.

Auburn, Maine: Non-Abusive Physical and Psychological Intervention, 1989. Petersen, C. B. “Doing Time with the Boys: An Analysis of Women Correctional Officers in

All-Male Facilities.” In B. R. Price and N. J. Sokoloff (eds.), The CriminalJustice System and Women. New York: Clark Boardman, 1982.

Porporino, F. J., and Marton, J. P. Strategies to Reduce Prison Violence. Ministry of the Solic- itor General of Canada, Programme Branch, Research Division, 1983.

Rice, M. E., Harris, G. T., Vamey, G. W., and Quinsey, V. L. Violence in Institutions: Under- standing, Prevention and Control. Kirkland, Wash.: Hogrefe & Huber, 1989.

Wener, R , Frazier, W., and Farbstein, J. “Building Better Jails.” Psychology Today, June 1987, pp. 4149.

RONALD WOODSON, B.A., is director of security for the, Michigan Department of Mental Health’s Centerfor Forensic Psychiatry in Ann Arboc Michigan.

Security and patient management in a forensic hospital

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