Schizoaffective disorder, major depression, bipolar disorder, alcohol dependence, antisocial personality disorder—it’s all in a day’s work for the staff at Bridgewater State Hospital.

The forensic psychiatric facility for the Massachusetts Department of Correction, Bridgewater not only provides excellent care for hundreds of patients with these and other mental and medical conditions, but also demonstrates extraordinary organization and teamwork with security operations. That combination of high quality care and interdepartmental integration earned Bridgewater State Hospital NCCHC’s Facility of the Year award.

As of January 2003 all medical, dental and mental health services are being provided by the University of Massachusetts, which employs all health services staff. Previously, UMass oversaw some of that work in partnership with another contractor.

Diverse Population
This hospital is exceptional in many ways, but especially in the diversity of patients served.

Whether they are new admissions, pretrial transfers or convicted, all patients are there by court order, according to health services administrator Susan Lantagne, LICSW. They come from not only state correctional facilities, but also county houses of correction and jails and courts throughout Massachusetts.

The courts refer them to Bridgewater for forensic purposes such as evaluation of competency to stand trial, criminal responsibility or ability to serve time in a penal setting, as well as clinical purposes. Forensic psychiatrists and psychologists provide evaluations to the court, while treatment teams take care of the patients’ clinical needs.

Patients admitted for evaluations generally stay from 20 to 40 days. However, those who are assessed as mentally ill, dangerous to themselves or others, or in need of hospitalization in strict security may be committed for treatment.

Working in multidisciplinary teams, providers deal with a full spectrum of psychiatric, behavioral and neurologic disorders, and medical disabilities. Some patients arrive under the influence of substances and need detoxification. Aggressive/assaultive behavior, self-injury and suicide risk are ever present.

As well, a significant number of patients suffer from chronic diseases that require immediate medical attention and follow-up.

Apart from the 300-plus hospital patients, the facility houses about 50 DOC inmates known as “cadres.” These men, who are not there for mental health reasons, live in separate quarters and perform tasks such as maintenance, food service and housekeeping.

Dealing With Difficulties
Not surprisingly, dealing with such a population poses numerous difficulties. Most fundamentally, Lantagne says, it often is difficult to obtain accurate information from patients, who often come in unmedicated. “They may be mute for days or floridly psychotic, making the assessment process quite challenging.”

To obtain information about a patient’s medical history, staff get in touch with family members and with community agencies that may have worked with the patient.

Complicating matters, state regulations concerning substituted judgment require court intervention before medication may be forced on a patient, except in emergency situations. The legal process can stretch out for weeks or months, during which time the patient may continue to go unmedicated.

Commenting on the state’s concern for patient rights, medical director Susan Skea, MD, says, “What gets lost is the morbidity of the psychiatric illness. We need to use other ways to manage sometimes violent psychotic patients, which may result in restrictive means such as seclusion.”
On the plus side, however, Skea points out that, “For some patients, this is best care they’ve ever had—not just psychiatric care, but also the best medical and dental care.”

Besides the various modes of evaluation and therapy, inmates can take advantage of an abundance of programs such as education, vocational training, day treatment, and art and music therapy.

It Takes a Team
A real strength of the hospital is its well-integrated staff, and it starts at the top. Superintendent Kenneth Nelson is an active hospital advocate, taking part in committees, meetings and quality improvement teams.

Though their functions differ, clinical and forensic staff work cooperatively, with the clinicians providing regular updates on the status of their patients. Nurses administer medications and treat routine needs.

The treatment team also includes mental health workers in each unit who support the nurses. Some of these workers do one-on-one observation of patients in seclusion. They receive special intensive training for this task, but still, Skea notes, “It takes a unique person to do this.”

That close involvement by mental health staff with secluded patients grew out of a performance improvement initiative to reduce the number of hours that patients spend in seclusion or restraint. The result: A new policy implemented last July.

Essentially, the goal is culture change, one that focuses on prevention as well as monitoring and communication so that observers can notify clinical staff not only when a patient requires intervention, but also when it is no longer needed.

The policy stipulates that only licensed or license-eligible staff may initiate seclusion or restraint. The hospital also developed a new crisis clinician program with hours extended later into the evening. New programming for patients provides more services and structure to prevent the need for seclusion in the first place.

“Data show that we are moving in the right direction,” says Lantagne.

In keeping with the emphasis on crisis prevention, the hospital also is working on a deescalation initative. Unlike in a traditional psychiatric hospital, the units are staffed mostly by officers with training primarily in security, not mental health. “The goal is to provide practical training and alternatives to assist officers in managing difficult situations,” Skea says. This initiative will make the environment safer not only for patients but also for the officers and other staff members.

It also meshes with the facility’s strong focus on education and training. “We try to work closely with correctional staff because it is also an educational opportunity for both parties,” says Skea.
Further, the hospital has relationships with UMass and other universities’ graduate schools in which social work and psychology interns work at the hospital for a year. In addition, an accredited fellowship program brings psychiatry students to the hospital or DOC prisons for a year.

“Corrections can be a hard sell,” says Lantagne. “With this program, students can see the opportunities for professional growth in this field. And for us, it’s a great source of employee recruitment.”

— About the Author: Jaime Shimkus is NCCHC's publications editor.

[This article first appeared in the Fall 2003 issue of CorrectCare.]