Conditions Worsen at Reinvented State Hospital

By Lee Romney and Rong-Gong Lin II

Dec. 15, 2005 12 AM PT

Times Staff Writers

After a scathing federal probe in 2002, Metropolitan State Hospital set out to do more than just fix its failings -- it aspired to become a beacon in mental health treatment, a model for the other state hospitals to follow.

The locked Norwalk facility, state officials decided, would be first to shift its approach from relying on drugs and restraints -- which federal inspectors had found objectionable -- to helping patients develop the skills to live on the outside. It would encourage them to help plan their own recovery, to learn about their diseases, mimic normal daily routines and hone such basic skills as cooking.

Three years later, a Times review of state data and legal claims -- including four recent suicides -- indicates that Metropolitan’s experiment has stumbled. Indeed, the facility is, in most respects, more dangerous for patients and staff today than it was in 2002. It is also more dangerous than any of California’s three other long-established mental hospitals. (Coalinga State Hospital, which opened a few months ago, was not included in the review.)

More patients hurt themselves, attempt suicide, are caught with contraband, escape, allege physical abuse by staff and allege rape -- predominantly by other patients -- than at any of the other three state hospitals, state records show. This happens despite the fact that Metropolitan houses roughly 600 patients, about half as many as each of the other three hospitals.

The spate of suicides -- after more than five years without one -- prompted Metropolitan’s president and chief of staff to suggest at a recent state Senate hearing that the so-called recovery model, adopted in 2002, might be imperiling patients.

“We’re experimenting with our patients here with unproven treatments,” Dr. Christopher Heh testified in September before a Senate committee. “I would say we need to revisit, re-look at the plan very carefully.”

The soul-searching comes amid intensified federal scrutiny of California mental hospitals. Napa State Hospital is reeling from a critical report this summer, and federal investigators are investigating conditions at Atascadero State Hospital. A review of Patton State Hospital, near San Bernardino, began this week. And Metropolitan is still negotiating reforms with inspectors from the U.S. Department of Justice.

Despite Heh’s concerns, state Department of Mental Health Director Stephen W. Mayberg and Metropolitan officials say their new approach has paid off, resulting in, for instance, shorter patient stays and fewer returns to the hospital.

They also say that Metropolitan has patients who are more difficult to handle than those at the other state hospitals.

Though most patients at Metropolitan and other state mental hospitals are committed by the criminal courts, Metropolitan houses the state’s largest proportion of severely ill people committed by civil courts, many of whom have not succeeded in less secure settings. Although it may seem counterintuitive, hospital officials say these patients tend to be more consistently disruptive than those coming through the criminal justice system.

Former Metropolitan Executive Director William G. Silva, who handed the reins to a replacement last month after 18 years, recently suggested that problems had been mostly resolved, pointing to the hospital’s recent accreditation by a national hospital review organization.

“Three weeks ago we met or exceeded national standards, so don’t talk to me about three years ago,” he told the hospital’s advisory board Nov. 16, shortly before his departure.

But statistics, legal actions and interviews with patients’ families and attorneys tell a different story. They suggest that the switch to a less restrictive environment in 2002 introduced a new set of problems:

* Patients harm themselves and attempt suicide considerably more often at Metropolitan than at other state hospitals. At Metropolitan, reports of self-harm, such as cutting and burning, were twice as high between January 2004 and last June as in the previous 18 months.

Although state officials say the recent suicides were in no way related, 20-year-old Cecilia Marie Russell, a gregarious patient with an impish smile who took her life in September, had found the hanging body of her roommate, Maria Garcia, 18, in May. Russell was distraught over the suicide, her parents and a former roommate said. Both women hanged themselves during the dinner hour, when patients could return to their rooms largely unsupervised.

Last week, a 36-year-old man was found hanging by a bedsheet in a bathroom. He died days later. Another patient committed suicide in 2004.

* Escapes are on the rise.

From January to June, there were 18 reported escapes from Metropolitan, double the number of the previous six months and by far the highest for any six-month period since mid-2002. Escapes from July 2002 through June of this year totaled nearly five dozen at Metropolitan, compared with eight from Napa, three from Patton and none from Atascadero.

In a five-day period last October, two teenage boys escaped from the facility and three teenage girls assaulted a nurse and stole her keys. Two of the girls attempted an escape. In May, five youths escaped, some of them by stealing a nurse’s keys.

* Patients’ allegations of rapes and other inappropriate sexual contact -- largely by other patients -- remain far higher than at other facilities.

There were 65 such complaints at Metropolitan for the three-year period beginning in mid-2002, compared with 39 at Patton, 21 at Napa and 3 at the all-male Atascadero.

In one sexual abuse case, a psychiatric technician took a 17-year-old patient off the hospital grounds for three months, keeping her with him until March 2003, according to the lawsuit she recently filed against Metropolitan. He pleaded guilty earlier this year to unlawful sex with a minor and was sentenced to state prison.

Her lawsuit contends that the employee took her to Mexico and put her to work as a prostitute. She ultimately made her way back to Metropolitan, pregnant. “The institution was charged to supervise her,” her lawyer, Tom Cifarelli said. “And they failed her.”

Metropolitan officials declined to comment on any specific case, but spokeswoman Catherine Bernarding said none of the rape reports was substantiated.

* Reports of alleged physical abuse by staff remain far higher than at other facilities, although they have dropped slightly since early 2004.

Seventy-three allegations of abuse were reported at Metropolitan in the last three years, compared with 38 at Patton, 33 at Napa and three at Atascadero. Bernarding said only one was substantiated and no patient was injured.

The parents of Richard Callender, 39, contend in a pending wrongful-death lawsuit that he was killed after five or more staff members held him down and beat him last October after he assaulted another patient.

An autopsy report said that Callender, who had schizophrenia and heart disease, had no visible injuries but probably died of asphyxiation because of the way he was restrained.

* Acts of aggression against the staff, including hitting, pushing or kicking, have more than doubled since mid-2002, although they dropped slightly last year.

“We don’t know when they’re planning something,” said Eliza Castillo, a Metropolitan nurse who was beaten by a patient in February. “Their motive may be to escape. The sacrifice may be a nurse.”

Castillo is a member of the bargaining unit for the Service Employees International Union Local 1000. She and other union representatives attribute increased patient assaults, in part, to staff exhaustion: Overtime hours in June 2005 were double those in June 2003, state numbers show.

At the same time, the new treatment model requires the staff to engage patients more actively and to spend more time on paperwork.

Metropolitan officials said it is unfair to judge the hospital by statistics, allegations and claims alone. With regard to escapes, Metropolitan in some sections is less secure by design, to protect the rights of juveniles and civilly committed patients who are not criminals. For example, when juveniles are escorted to a school building across open grounds, their legs are unshackled and some have escaped.

Other state hospitals, which treat a higher proportion of patients referred by criminal courts, have tighter security. And the same is true, officials say, in Metropolitan’s criminal compounds, where there have been no escapes reported since 2002.

In addition, false allegations of rapes, assaults and other improprieties are not uncommon among patients with personality disorders, Bernarding said. Even so, each allegation is investigated internally and those who allege to have been raped are also referred to outside doctors for medical exams, Silva said.

Some family members say that in the chaos of the wards, genuine abuse can go on unchecked.

When Bernadine Forsythe visited her son, Ron, in June 2003, his eyes were blackened. Ron Forsythe, now 35, said a psychiatric technician beat him up. Later, with the help of a court order, she learned that the accused staff member had blamed another patient and had refused to write a report, as required, despite her son’s profuse bleeding.

The hospital was unable to determine who injured Ron Forsythe. The technician no longer works there and could not be reached for comment.

“Look at all the suffering that goes on undetected,” said Bernardine Forsythe, who has sued Metropolitan. “The only way I got these documents in my hand is because I got a court order.”

It is unclear how much of Metropolitan’s plight is related to its new approach to treatment, begun in 2002. What is clear is that the hospital has had difficulties over the years balancing the need for safety and security with patients’ rights to a certain degree of autonomy and privacy.

Before the 2002 federal investigation, a great shift was underway at Metropolitan and the other state mental hospitals toward housing mostly criminal offenders. (Now such offenders account for 90% of patients statewide.) Metropolitan also took on juveniles for the first time in the late 1990s.

In adapting, said Mayberg, the state’s mental health director, Metropolitan focused on keeping patients and staff safe at the expense, federal investigators eventually concluded, of patients’ rights.

U.S. Department of Justice findings issued in 2003 and 2004 criticized the juvenile and adult programs at Metropolitan for excessive seclusion and restraint and improper prescription of drugs to control behavior.

Even before the federal findings, Mayberg launched the new approach to treatment, known as the “recovery model,” which hospitals in Virginia had embraced after a federal investigation there. It since has gained popularity in other states. Some psychiatrists dismiss the approach as inappropriate for psychotic patients who pose a danger to themselves and others. But proponents say all patients can benefit once stabilized.

Rather than spend time listless or restrained, the theory goes, patients participate in their treatment and practice social interaction. The goals are empowerment, hope and getting out.

At Metropolitan, forcing reluctant patients into groups for treatment led some to lash out, officials acknowledge. There was resistance among staffers too. Many left, Silva said, but “now we have a strong structure in place. We’re starting to see some of our labor pay off.”

Indeed, hospital and state officials say, by some measures they have met their promise for improvement -- at least in areas of concern to federal inspectors: The use of multiple drugs has declined, as has the use of restraints and seclusion.

Mayberg is not proclaiming unmitigated success. “Toddlers learning to walk are going to stumble,” he said. “Every time there’s a suicide, that’s awful. Nothing makes that OK.”

Times staff writers Sharon Bernstein and Steve Hymon contributed to this report.

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Metropolitan State Hospital troubles

Despite being far smaller than the three other long-standing state mental hospitals in California, Metropolitan reports more of the following problems. In some respects, patient safety and security have worsened since the Norwalk hospital adopted a new approach to treatment in 2002.

Comparing Metropolitan with other state mental hospitals

(Serious incidents in selected categories, July 2002 through June 2005)

Self-inflicted harm

Atascadero: 1

Metropolitan: 31

Napa: 12

Patton: 2

Escape/unauthorized absence

Atascadero: 0

Metropolitan: 58

Napa: 8

Patton: 3