Online NewsLetter

Responding To The Challenges Of Violence

The population of a mental hospital often mirrors the community it serves. This is no less the case with Sheppard Pratt, a facility which has expanded its inpatient and outpatient services. At the same time, the dictates of managed care have resulted in only the most severely ill patients being admitted for inpatient evaluation and care. Given the short length of stay, the number of admissions has dramatically increased, up to threefold in the past five years. Among this volume are more aggressive and homicidal children and adolescents. This development, though partially expected in a city with a high rate of violent crime, has been nonetheless startling and both frightening and dismaying to staff. To be sure, disturbed individuals have always been admitted for care. However, these patients have generally been psychotic or manic; now, clinicians must deal with an increasing number of potentially dangerous youths and those whose behavior has criminal implications. No longer are children and adolescents seen as innocent or harmless. Highlighting the dilemmas associated with assessing risk are the following cases from various clinical settings at the hospital. All of these occurred within a one-year span of time.

Inpatient Vignettes
Two hospitalized adolescents kicked in a door, escaped from the ward, ran to the garage of the adjacent general hospital, and assaulted a physician and stole his car. They were apprehended and returned to the hospital where only one showed any degree of remorse. A 14-year-old boy was hospitalized for depression and suicidal thinking. After admission, he told staff that he was being charged for attempted murder of a teenage girl who had died of exposure after a gang of boys who had been drinking with her raped her and left her out in the cold. A 15-year-old boy was admitted because he wanted to kill the daughter of his father's live-in girlfriend. His parents had divorced when he was a toddler and he had lived in another state with his mother until recently when she felt that she could no longer manage him. An intelligent boy, he was preoccupied with blowing things up, stating he wanted to be a demolition expert when he grew up. He was also preoccupied with the movie Natural Born Killers, stating he had watched it numerous times and went to sleep at night listening to the soundtrack. He knew where his father kept his guns and graphically described how he would kill the 11-year-old girl, then kill his father and his girlfriend when they got home. A 15-year-old girl was admitted status post suicide attempt by gun shot wound. It was realized during the course of her hospital stay that she had paid her boyfriend to kill her, giving him a check for $65. A 17-year-old was hospitalized for severely assaulting a staff person in a residential treatment center. He too was preoccupied with the movie Natural Born Killers and described how he wanted to go on a killing spree. He had a history of drug abuse, and had been abused as a child by a paranoid, alcoholic father.

Day Hospital Vignettes
A 16-year-old was evaluated for homicidal thoughts. He had been in the day hospital several days but was not talking with staff. He wore dark glasses and generally appeared depressed. On interview he described how he wanted to kill the neighbors who he felt made fun of him. He shared that his favorite movie was Natural Born Killers and that he had seen it several times. When asked who would care if he killed someone, he said, "No one." A 15-year-old with a history of attention deficit disorder and behavior problems began to have trouble accepting limits in the day hospital. He had recently been discharged from inpatient care where he had been admitted because he stated he wanted to kill his stepfather. He also had a significant history of drug abuse, including glue sniffing. He arrived one morning slightly agitated. Another patient reported that he had a gun and intended to harm staff. He was confronted with this information and loudly agreed, stating he wanted to kill staff. He was taken to the local emergency room and ultimately admitted to the state forensic unit. A pellet gun was confiscated from his backpack.

Level V School Students
A 15-year-old student reported that she had received a threat from an ex-boyfriend; he planned to come to the holiday dance with a gun and shoot her new boyfriend who was also a student at the Sheppard Pratt school. This information was widely disseminated through the high school students and the threat was felt to be quite real and concerning. Both students agreed to not attend the dance and security was alerted and available. A high school boy was reported to have a knife in his backpack. He refused to let his pack be searched and was sent home from school. His grandmother later reported that indeed there had been a knife in the pack. A 14-year-old boy hid in a bathroom and raped a girl who entered. He was convicted of the crime and is presently at a residential treatment facility. A 15-year-old boy assaulted a student in the community with a baseball bat. He is currently charged as an adult with attempted murder. These alarming cases evoke fears for both patients and staff. They also confront the security personnel at Sheppard Pratt with a level of danger previously not experienced. The response of the institution has been severalfold. Violence prevention and risk management training have been emphasized. Clinical staff have had in-service seminars on violence prediction and the assessment of dangerousness. Written documentation of threats and behavior has become an important means of both bolstering clinical decisions about privilege levels and discharge, and has also helped in justifying retention in the hospital to the insurance industry. Issues regarding the informing of potential victims (Tarasoff) have been discussed. Two forensic consultants have been retained by the hospital and can be called upon to see cases of concern to staff. Their expertise with dangerousness and legal complications have been beneficial to therapists who are often enmeshed with clinical issues. Most intriguing has been the implementation of media training. Several of the patients overidentified with the heroes in the film Natural Born Killers, and efforts were made to acquaint staff with other movies, videos and songs in the world of youthful patients. For example, knowledge about violent videos allows some assessment of how much an adolescent patient might be preoccupied with anger or rage.

Many of the changes occurring at Sheppard Pratt reflect a privatization of the public sector whereby patients who once were treated within the public hospital system are now managed by hospitals previously funded by private insurance. One unresolved issue in some of the cases mentioned above has been limitations in length of stay. For patients with severe character pathology, there are exceedingly scarce resources. Brief hospitalizations for the purpose of "acute stabilization" are the rule. Such a stay is then immediately followed by residential placement for the few patients where this is economically justifiable. Gone are periods of transition whereby the patients can be graduated to and tested within a new environment. Violence is a problem not easily solved. Unlike a psychosis or depression which can remit, deeper pathologies are involved. Treatment at Sheppard Pratt is both a beginning intervention and one which draws social and clinical attention to a major problem of our time.

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Last modified: Wednesday, April 16, 2014

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