When the staff members on Ward G at Western State Hospital got word on the Friday morning before Easter that 22-year-old mentally retarted man was being sent to their unit, they knew they had to act as swiftly as possible.
The weekend was approaching, a time when the already understaffed ward in the mental hospital would have just two aides to watch over 20 patients, many of whom were notoriously violent and sexually aggressive. That meant little protection for physically vulnerable patients such as the new arrival, a short, chubby, boyish-looking young man from Northern Virginia who staff members said should not have been there in the first place because the ward had no program to treat the mentally retarded.
"We knew if he stayed there over the weekend that he was going to get either raped or beat up for resisting," said social worker Dennis Draper Jr. "We decided he would be better off in a car riding around Northern Virginia than to stay in our ward."
It only took an hour for Draper to arrange to send the young man back to his father's home. But when Draper went to the ward, he was already too late. He found the man on a bed in a back dormitory cubicle, being sexually molested by another patient.
Here at Western State, such incidents have become a way of life on many wards, according to interviews with staff members and patients and an examination of records at the hospital, one of Virginia's four major public mental institutions and a main repository for mentally ill persons from Northern Virginia. Despite a wholesale reduction in patient population and other changes over the last 15 years, the hospital is still largely a warehouse where many patients can expect little therapy beyond regular doses of tranzuilizing drugs, where idleness and boredom dominate, alternating occasionally with intimidation and violence. Some examples:
Social workers in the hospital's geriatric center compiled a list of more than 600 violent incidents last year but say the hospital's administration has refused to acknowledge the problem. Administators say that the incidents, while unfortunate, are no less frequent at other institutions.
In one unit designated for Northern Virginians, officials mixed about 20 accused or convicted felons undergoing psychiatric examinations with a dozen chronically ill and vulnerable mental patients for about six months.The result, according to unit director Charles Spraker, was a series of weekly beatings and other incidents that top hospital administrators ignored until a brain-damaged 27-year-old Alexandria man was sexually assaulted. Hospital director Willian Burns blamed the problem on overcrowded that prevented him from transferring the chronic patients to other wards.
Hospital records show Western State has been a state leader in use of "seclusion" -- locking patients in solitary confinement, sometimes after being stripped naked to prevent suicides. Staff members say the practice has often been used to punish recalcitrant patients in violation of state patients' rights regulations. Burns says use of seclusion has dropped greatly over the last year and says it is only used as a last resort.
Workers also say patients are sometimes intimidated or tricked into taking medication with the implicit conscent of the hospital's administration. In one recent incident, two social workers say they were harassed by administrators after accusing two doctors of tricking a patient into taking a drug with potentially hazardous side effects that the Food and Drug Administration has not approved for the patient's particular illness. Hospital officials say their investigation exonerated the doctors.
Most of Western State's problems were supposed to be solved by the massive transformation the hospital has undergone in recent years.The old stench-ridden dormitories, some of which dated back to before the Civil War, have been abandoned, replaced by bland but well-scrubbed modern facilities just east of this Shenandoah Valley town 150 miles southwest of Washington.
Gone, too, are the old therapies that at one time included crude lobotomies and large doses of electric shock and insulin-induced comas. State laws, which once allowed patients to be locked up against their will and confined indefinitely without a court hearing, have been replaced by new statutes designed to give patients a full array of legal rights.
But the problems have not stopped. Western State has gone through three different directors in the last five years, one of whom, Coen Plasburg, was forced to resign last year after a management review team reported widespread violations of state Department of Mental Health and Mental Retardation policies on seclusion and medication. The hospital also has failed to achieve national accreditation and last month was suspended, along with two other Virginia facilities, from the state's Blue Cross program.
A new administration under Burns, Plasburg's successor, took over last August with the promise of dramatic changes. But staff members say reforms so far have been few, and Burns and other top administrators have been locked in open warfare with many of the hospital's social workers over issues of violence, seclusion and forced medication. The social workers, who have filed a series of written reports charging administrators with patient abuse due to negligence, say they are being harassed and threatened with dismissal as a result, a charge Burns and State mental health officials deny.
Meanwhile, for most patients, there has been little variation in their daily routine. Most still spend their time sitting in day rooms watching soap operas on color televisions, some tranquilized into a stupor, or wandering the hallways.
Burns said the hospital's organizational system "was already in a state of breakdown when I got here." He contended in a recent interview that major improvments will occur in time. "People are working very hard," he said. "There are things they're not able to do because they don't have the resources. I knwo we don't have outstanding programs but I think we have the right kind of perspective."
But other staff members, who have seen previous reforms come and go, predict little will change. "On most of the units, it's still paperwork and pushing pills," says Robert Claytor, the hospital's Episcopal chaplain, who says of his eight years at Western State, "It was a warehouse then, it's a warehouse now." Violence
Over the last decade, as part of a nationwide deinstitutionalization movement, the hospital's population has dropped by nearly two-thirds to 1,050. The shrinkage was supposed to help transform Western State from a warehouse into an institution where truly sick people could come for modern psychiatric treatment. But as patients were eliminated, so was the hospital staff, from 1,460 to 1,312 in the last two years, due to reductions ordered by the cost-conscious Dalton administration in Richmond.
The reductions mean there is only one doctor, not always a psychiatrist, for 67 patients, one psychologist for 107 patients, one social worker for 152 patients -- ratios hospital administrators contend are crippling. "The resourses get cut faster than the population goes down," said hospital medical director Glenn Yank.
Staff cuts and emphasis on reducing beds have led to overcrowding throughout the state system. Violence and a near-riot at the forensic unit at Central State Hospital in Petersburg last summer prompted state officials to transfer about 20 convicted or accused felons to Western State. All were certified as "Nondangerous," according to hospital director Burns, who said they were judged safe to mix with about a dozen chronically ill patients on a Northern Virginia unit.
But unit director Spraker said of Burns' statement: "To be blunt with you, that's cochamamie. The people we received have been convicted of crimes ranging from assault and battery to murder and they are violent. We had violent incidents and fights almost every day."
Spraker and other staff members say they warned administrators for six months that mixing the two patient groups was dangerous and memos confirm their claim. One, dated Dec. 30, 1980, from Spraker to Burns, asked for the transfer fo the "chronics," and warned that "due to the changing population . . . and the more hostile and aggressive patients there, the chronic patients are in jeopardy at all times of being either hurt or abused. . . ."
The warnings went unheeded until two months later, after a hospital aide discovered two accused felons on the ward sexually molesting a brain-damaged 27-year-old patient named James, a moon-faced, slightly built man whose pajamas they had ripped off. The next day, James was transferred to another ward, followed eventually by a half dozen other chronics.
State Deputy Mental Health Commissioner C. William Brett contends much of the violence at Western State is inevitable. "Those kinds of things happen in mental hospitals," said Brett. "I don't like them and you don't like them but people who are upset, who are psychotic, sometimes tend to act out that way."
But critics such as Gary Hardley, Western State's quality assurance director, and Brendan Buschi, the hospital's social work director, say negligence on the part of staff members and top administrators is at least partly to blame. They point out that the aide who intervened in the assault on James recorded the incident only as "horseplay" in the ward's official log and officials did not learn of the incident until another patient reported it the next day. The aide was later temporarily suspended.
The sexual abuse of a teen-aged male named Peter by three other male patients on the hospital's adolescent unit in April 1980, occurred at night while two staff members who should have been policing the area were playing backgammon in an enclosed nurse's station, according to an investigative report. Despite that finding, no disciplinary or legal action was taken against the staff members or the alleged assailants.
Violent incidents are also common in the hospital's geriatric center, according to social work supervisor Donald Vessey. He compiled a list of 305 specific incidents -- most of them resulting in bruised, scratches and other minor injuries -- during 1980 from hospital records, and his list included another 315 incidents where the cause of injury was unknown. Vessey said he believes hundreds of other incidents went unreported.
Burns contends the number of incidents is not unusual for a unit that totals 400 patients. He says that the statistics compare favorable with those from other state institutions. But Hardley, who was asked by Burns to evaluate Vessey's data, concluded in a recent report that "serious assaults happen routinely . . . incidents which could be avoided if proper steps were taken." Seclusion
Thursday afternoon in a day room on Western State's Northern Virginia unit. Medication was dispensed an hour or so ago and now most of the dozen men sit passively in lounge chairs or nap on couches. Some stare ahead glassy-eyed, others hunch their shoulders and bow their heads as if in prayer. Almost no one watches the television blaring a soap opera at one end of the room. Two aides sit in an adjoining nurse's station talking animatedly about the weekend to come. After dinner, the men will be consigned for the night in an open dormitory just past the day room, where the only privacy is behind the closed door of a bathroom that does not lock.
On wards such as this one, staff members say they must sometimes rely on methods such as solitary confinement and heavy medication to control a patient population that greatly outnumbers them.
Some states have prohibited secluding patients in locked rooms because of the potential for abuse. Virginia regulations allow the practice only when absolutely necessary to prevent serious injury or disruption and require that a physician must personally see a patient and sign the order before seclusion can occur.
Each psychiatric ward has its own seclusion cell, a 6-by-8 foot room with one window, a bare mattress and no other furniture. Patients can be confined there for up to eight hours by a doctor's order, which must then be renewed by the doctor for the seclusion to continue.
Western State, because of its shortage of doctors, is the only Virginia mental insitiution granted a special variance allowing psychologists and nurses to order confinements. The variance, which violates standards set down by the nationally recognized Joint Commission of Accreditation of Hospitals, was granted by Mental Health Commissioner Leo Kirven last year despite statistics indicating that seclusion was commonplace at the hospital.
In 1979, according to figures compiled by the hospital's patient advocate office, seclusions averaged more than 1,000 hours per month, with the record-breaking month of April showing more than 600 seclusions totaling 2,319 hours. That made Western State "one of the highest, if not the highest" in Virginia, according to state patient advocate Gloria DeCuir.
"There's no question it's been used too often in the past and sometimes as punishment," said DeCuir, who was once social work director at Western State. "The question is, is seclusion used in lieu of treatment programs and the answer is, sure, that has happened."
Since it does not meet standards on seclusion and other patient-related issues, Western State is not accredited by the Joint Commission. As a result, Blue Cross of Virginia's board of director's last month removed Western, Central and Eastern State hospitals from what it calls "participation status," a move company spokesman Suzanne Munson estimates will cost the institutions about $300,000 in annual insurance payments.
Burns concedes seclusion may have been abused in the past, but notes that the number of recorded seclusion hours has dropped since his arrival.
"It may in some instances be the only reasonable alternative," said Burns, who suggested that the alternatives in a hospital as understaffed as Western State can be equally grim. "I've worked in New York State where seclusion was not allowed but there was a heavy use of mechancial restraint and I've worked in other systems where you couldn't use restraint or seclusion but everybody was heavily medicated." Medication
Medication has also become a heated issue at the hospital in recent months, mostly centering around use of carbamazepine, a powerful anticonvulsant, marketed under the brand name Tegretol. The Food and Drug Administration has approved use of the drug for patients with difficult-to-control epileptic seizures, but says the medication should not be used as a "drug of first choice," because of "serious and sometimes fatal abnormalities of blood cells," according to a warning published in the Physicians' Desk Reference.
Some doctors at Western State have begun using Tegretol on patients suffering from manic depression, citing claims in research literature that the drug may help patients who either cannot or will not take other medicines. The FDA has not sanctioned Tegretol for such use, so the patients must sign "informed consent" forms to satisfy regulations.
In a written patient, abuse complaint in March, geriatric social worker Liz Tsatsios reported that two physicians in her ward had tricked a female patient named Irene into signing a consent form for Tegretol. One doctor, accoring to the report, falsely told Irene that the other doctor, whom she disliked, did not want her to take the medication. After the other doctor confirmed his colleague's story to her, she signed the form and agreed to take the medicine.
Burns said the abuse investigation he ordered cleared both doctors of misconduct. What they used on the patient, he contends, was paradoxical therapy. He explained: "You do something more or less paradoxical for the purpose of getting the outcome you really want. It sounds like tricking to you, yet it's legitimate treatment approach."
Tsatsios and Vessey, her supervisor, say they were harassed by one of the doctors involved in the incident who demanded to see their supposedly confidential complaint report. Draper and his supervisor say they were encouraged by hospital officials to drop their abuse complaint about conditions in Ward G. And Buschi says that when he filed a written complaint alleging patients were being subjected to unauthorized research with Tegretol, he was cross-examined for four hours by Burns, Deputy Commissioner Brett and three other state officials, including department personnel director Anne Goodman. The main topic, said Buschi, wasn't the abuse complaint but rather his competency as social work director.
Brett denies any harassment has occurred. Of the session with Buschi, he said: "Not one intimidating thing was said . . . [and] nothing happened to him. Not one thing in this world happened to that young man."
A sunny Friday morning outside the Shenandoah Geriatric Treatment Center here. Seated alone on a bench, arms folded over a paunchy stomach, straw hat shading his bald head, is Charles Ware, 74, an ex-farmer who has spent most of the last 30 years here.
"They'll have to carry me out of here," says Ware. "I practically had to commit a felony to get back in 1975. There's no other place to go. The outside world is worse."
A few hundred yards away, in front of the Stribling Building, where Western State's limited recreation facilities are located, sits Mary, 21, a thin, curly-haired Charlottesville women who says she was committed here by her parents after some intensive drug use. Mary wants to leave.
"Half the staff say I don't belong here," she says. "This place reminds me of the Twilight Zone."
The patients who complain or rebel, says Episcopal Chaplain Claytor, are the healthy ones, the ones with enough ego left to survive. Most of the others, many of them long ago abandoned by family and friends, are doomed.
Claytor recalls some of the funerals he has conducted for patients who died at the hospital without the presence of even a single family member. "There's nothing like the feeling you get when it's just you, the funeral director and the corpse and nobody else gives a damn," he says.