Thursday, June 22, 2006

"Taking your life into your own hands just to get the job done:" Missouri Mental Health Institutions

During my 16 years running the health and safety program for the American Federation of State County and Municipal Employees, I spent a lot of time out in the field, providing training for our members and listening to what their lives were like from 9 to 5 (or 5 to 1, or 1 to 9) while they worked.

A lot of those jobs I'd never want to do -- even if they paid decently, which most of them didn't. Close to the top of that list was mental health workers. I had enormous admiration for the caring people who did those jobs, and little understanding at first for how they could tolerate the working conditions, the chronic understaffing and constant threat of assault day after day. The answer was that they cared about people -- and they needed a job. The union, and the control that gave them over some of their working conditions -- even if limited -- was what made it tolerable to many.

The St. Louis Post Dispatch ran a series last week about horrendous conditions in Missouri's public and private mental health institutions. In summary,
Mentally retarded and mentally ill people in Missouri have been sexually assaulted, beaten, injured and left to die by abusive and neglectful caregivers in a system that for years has failed at every level to safeguard them.

While recent publicity over two of those deaths has sparked outrage across the state, a Post-Dispatch investigation has uncovered widespread mistreatment in 19 large state institutions and hundreds of smaller group homes supervised by the state across Missouri.

The abuse has been largely shielded from the public by broad secrecy laws, shoddy investigations and ambivalent police and prosecutors, and it has been perpetuated behind a series of broken promises by state officials to do better.

The abuse and neglect can be measured in numbers: 2,287 confirmed cases of abuse and neglect of residents since 2000. Of those, 665 resulted in injuries with 21 deaths.

And it is reflected in the skepticism of advocates, families, auditors and some caregivers themselves, who suspect that much more abuse and neglect has never surfaced in reports, lawsuits or the state database set up to track trends.
The series is chilling. Read it all if you have the stomach.

There is one part that is mandatory reading. Although the focus of the series is the "abusive and neglectful caregivers" as well as the criminally ineffective state oversight, the authors -- Carolyn Tuft and Joe Mahr -- also take the time to discuss the hazardous conditions, low pay and lack of support that the caregivers work under, and how those conditions contribute to the abuse.

They also acknowledge that they're not trying to accuse all workers of abuse.
Across the state, there are thousands of workers who provide quality care to mentally retarded and mentally ill residents. Parents offer story after story of caregivers who go beyond the job requirements, holding birthday parties or taking residents on shopping trips or out to eat.

But state officials and private facility operators acknowledge that the poor working conditions make it easier for bad workers - and some good ones - to mistreat the people they're supposed to be protecting.
The Mental Health Commission, which oversees Mental Health's management, noted in a joint statement this month that it's "abundantly clear" that workers "desperately need higher levels of support, leadership, and continuing education in order to function in their vital role.
First, there's the lack of training and support:
Once hired, new employees get two weeks of training and then spend a week watching other aides do their jobs. The training includes 16 hours learning how to manage aggressive residents and four hours on how to prevent neglect and abuse.

The private sector has fewer training requirements. Caregivers who work in both public and private facilities say the training is less extensive in private homes, particularly specialized care for some of the most challenging residents.

They receive training in abuse and neglect, emergency drills, and how to speak to residents and their families. They also must be certified in CPR.

But sometimes they don't keep current with their certification - a problem cited in a death in a Kansas City group home in 2001.
Then there's the pay:
Caregivers are paid about $9 an hour - making it hard to keep, recruit and train workers on how to handle challenging situations that can quickly evolve into abuse or neglect.


State officials, advocates and researchers acknowledge one of the best ways to make the job seem more like a career is simple: Pay more.

The average pay is $19,000 a year. And that's for a worker in a state facility. Those in private facilities commonly make less money, with fewer health benefits.

"We expect them to do it for a pittance of pay," said Bill Edmonds, the retired superintendent of a state-run facility in Nevada, Mo. "I had people working for me on food stamps, and that's a shame that people doing that kind of work have to rely on public assistance."

A 2004 study by The Associated Press found the Department of Mental Health had the highest number of workers who qualified for welfare benefits of any state agency in Missouri.

The lower pay makes it harder to hire people, said Felix Vincenz, who in February was named the head of all 19 state-run facilities.

"I think too often we've been in the mode of 'Let's take whoever comes across' because it's so challenging to get folks on board on some of these low-level positions," Vincenz told the commission this spring.

Some caregivers must work other full-time jobs to make ends meet. And then there's the forced overtime in state centers, some of which are so short-staffed they require workers to do two double-shifts a week.

Joe Lawrence, spokesman for the state workers' union, the American Federation of State, County and Municipal Employees, blamed state officials.

"When you have the worst-in-the-nation state-employee pay, on top of chronic understaffing and chronic overtime, they are fueling the turnover," Lawrence said. "This will leave staff vulnerable."

Researchers say low pay is a problem across the country. In Missouri, there's little debate from Department of Mental Health officials, who say they wish they could pay more.

In four years, the department's General Revenue funding was sliced by a tenth - resulting in cuts to the state workforce of 16 percent. This year, the Legislature gave back nearly all of the shortfall.

The new money will pay for more workers and a 4 percent raise for state workers - about $760 a year more for the average worker. The Legislature also approved a 7 percent boost in the amount paid to private facilities for each resident, but it is up to the providers how much of that will go to workers.
Then there's the violence and injuries suffered by the workers:
Police reports and state records show they have been hit, slapped, punched and stomped on by the patients they care for.

They've suffered black eyes, shattered teeth and broken noses, ribs, jaws, shoulders, cheeks and eye sockets.

Prisons may look more dangerous with their razor wire and high security but state workers compensation data shows that it's far more dangerous to work in a state facility caring for mentally retarded or mentally ill residents.

Workers who care directly for mentally retarded residents are four times as likely to be hurt by a resident as a prison guard is to be hurt by an inmate, according to a Post-Dispatch analysis of state injury data.

For workers who care for the mentally ill, the rate is nearly three times as high, the analysis showed.

At least 135 times since 2000, workers have filed police reports, complaining about such things as residents pummeling them, choking them unconscious and throwing urine on them.

State data shows the most abuse of workers occurs in the psychiatric hospital in Fulton, which houses some of the state's most dangerous mentally ill criminals.

In the state's 2004 fiscal year, Fulton workers suffered 331 injuries at the hands of patients. That is more injuries than prison guards suffered that year at the hands of inmates in the entire state correctional system.

State workers and officials offer a slew of reasons for the violence against workers across the system - chronically short-staffed facilities, frustrated patients who lack the mental capacity to control their anger, and caregivers who lack the proper training to calm those patients.

Department of Mental Health Director Dorn Schuffman said that prison guards must only ensure inmates don't escape or hurt each other, and they often do it from behind protective barriers. Mental health workers must be "therapeutically engaged" with residents, and deal much more passively with residents who turn violent.

Last year, the state began a pilot program at Fulton to teach workers safer ways to restrain violent residents. They hope to get federal money to expand it to workers across the state.

"A lot of these situations occur where our staff doesn't feel safe and may adapt ways (to cope) that are inappropriate," Vincenz told the commission.

In the meantime, the level of violence has spread fear among some workers. That's particularly true at Fulton, said Kevin Morris, who has repaired equipment there for eight years.

Each morning Morris drives into the center parking lot and walks through electronic gates that clank shut behind him. Once inside, he said, there is no protection from violent patients. This spring, he watched a patient grab an aide by the neck and beat him so hard the aide's glasses flew off and his ear began to bleed.

"You are really taking your life into your own hands just to get the job done," Morris said. "You have to always be looking behind you. It's not a pleasant place."

Recent research suggests the violence may have a chilling side effect: Fueling abuse and neglect of patients throughout the system.
One thing the authors fail to mention is Missouri is one of 26 states where public employees have no OSHA coverage. Although federal OSHA has not been particularly aggressive in enforcing safe working conditions in mental health institutions, the agency did issue guidelines for preventing violence for health care and social service workers. Although federal OSHA has not cited companies for workplace violence hazards in this administration, some states with OSHA state plans, such as California and New York, have been more active.

Missouri, until recently, was one of the many states in the country without laws allowing collective bargaining for public employees. Missouri workers finally won that right in 2001, only to have it taken away last year by newly elected Governor Matt Blunt.

Finally, it's reassuring to see that some of the many letters to the paper recognized the conditions under which the employees work.

This, from a nursing home worker:
Now, I don’t believe for a moment that all personnel at either nursing homes or homes for the mentally handicapped are at fault. Some of these people–at near minimum wage–bust their fannies to do what they can for their clients. But unfortunately even the best of them can be overwhelmed. If you’re assigned to care for 20 clients when reality dictates that you can only realistically care for 8, obviously the care you are able to give suffers. I think that many of the conciencious employees end up quitting because they can’t stand what they see day to day and feel they are letting their charges down. When they leave, that opens the door to the lazy, inept, and abusive. They’re the only ones who stay because they don’t care about their charges and really don’t have to in order to keep their jobs. I don’t know what the answers are, but increasing staff rather than decreasing it to save a few bucks would be a good place to start.
And this follow-up:
I agree - in addition to increasing staff, increasing education for the staff that need it should be addressed. There are amazing workers in these facilities that would die before they’d allow any sort of abuse to happen to their clients. Unfortunately as you stated, homes are drastically under-staffed. You have made so many good points. Direct care is HARD work. I couldn’t handle it when I did it. Great post.