Amid Growing Risk, Safety Issue Creeps Into the Minds of Mental Health Staffers

Social worker Kathleen Kott recalls the time a psychotic woman came at her with a butcher knife.

Kott, an Orange County mental health worker, was interviewing the woman to determine whether she needed to be hospitalized. Kott looked away a moment to phone for an ambulance, then looked up to see the client charging her.

“She was moving the knife slowly from side to side,� said Kott, who wrestled the weapon from the woman’s grasp.

Psychologist Michael Foust remembers the day he was working at the county’s Santa Ana mental health clinic when a patient reported to a small anteroom for a psychological test, calmly took out a gun and shot herself in the head.

Nearly 2 years later, the incident still shocks him--not just that it happened but because he knows how much worse it could have been. “Potentially she could have used the gun on any one of us,� Foust said softly.

Recent incidents in Los Angeles County, including one in February when mental health worker Robbyn Panitch was stabbed 31 times and killed by a patient, have mental health workers in neighboring Orange County worried that violence could strike them too.

Administrators are discussing installing hidden alarms in each of their eight outpatient clinics. They are also beefing up staff training in how to calm agitated patients, adding a seminar this summer in crisis intervention and “how to defuse an explosive situation.�

The issue of mental health workers’ safety has drawn statewide concern. Assemblyman Tom Hayden (D-Santa Monica) has introduced a bill that requires county mental health agencies to draft a security plan. In the absence of such a plan, the bill says, county workers may refuse to meet with a potentially dangerous client.

And, troubled by the Panitch slaying, the state mental health director, Michael D. O’Connor, recently urged county mental health agencies to work with employee unions to improve their training in preventing assaultive behavior.

The hope is to make a potentially dangerous job less dangerous. Attacks on workers are rare, mental health officials say; most mentally ill people are not a threat to anyone but themselves.

But around Southern California, county mental health administrators and psychiatric technicians alike acknowledge that the people they treat--usually people too poor to afford private therapy--are increasingly volatile.

“We’re dealing with people here who’ve been through state hospitals, who are off medication . . . hard to handle,� said Alan V. Albright, an Orange County mental health coordinator who is in charge of staff training. “It’s not like we’re in private practice and can pick and choose who we treat.�

Lately, many of the county’s clients are homeless and mentally ill.

And some of the patients who visit county outpatient clinics have carried guns, knives--or, in one December, 1987, incident, a homemade hand grenade.

So administrators are quick to acknowledge that a mental health worker could be killed in Orange County too.

“I always live in the nightmare of what happened� in Los Angeles County, said Timothy P. Mullins, Orange County mental health director. “It’s going to happen somewhere, sometime. . . . We do not run clients through metal detectors. We haven’t yet reached that state of siege.�

‘Can Happen Anywhere’

Agreed Douglas C. Barton, deputy mental health director: “These things can happen anywhere in L.A. or San Diego--or Santa Ana. We have a very similar patient population in our mentally disabled homeless.�

Part of their problem in treating these difficult patients, Barton and other experts on mental health explained, has come from frequent budget cuts for mental health as well as a major policy shift in treating the mentally ill.

In the 1950s, schizophrenic, manic-depressive and other seriously mentally ill patients were held in state mental hospitals. But in the early 1960s, new anti-psychotic drugs allowed many of these people to make a remarkable recovery. In addition, legislation discouraged “warehousing� mental patients and freed them from mental hospitals to be cared for in their communities.

But local officials contend that they were never prepared for the seriously disturbed patients who came home.

“Twenty years ago, these patients would not be treated in Orange County,� Barton said. “They would be in state hospitals.�

But local mental health professionals cannot send many of the chronically ill patients back to state hospitals because some of the facilities have closed over the last 2 decades. “Twenty years ago, we had 30,000 beds available for civil commitment. Now we have only 2,500 beds available for civil commitment,� Barton noted.

$200-Million Cut Vowed

And the coming fiscal year could be worse, Barton predicted. Because if Gov. George Deukmejian does not get the budget he wants, he has threatened a $200-million cut in all mental health funds--about a $13-million cut to Orange County mental health.

In this tense fiscal environment, there is not a lot of money to spend on hidden alarms or security guards.

Although concerned about safety, the county’s mental health professionals stress that they also want to balance that with preserving the “therapeutic environment� of a clinic.

“Perhaps it’s negligent of us, but we don’t routinely inquire if people are carrying weapons,� Foust said. “The whole nature of this business is trying to engender some kind of safety or trust� between therapist and patient.

For that reason also, some mental health workers react with horror to the suggestion that perhaps they should carry guns. And some workers say they don’t want sheriff’s deputies or security guards at their clinic.

There is one exception, however. Foust’s Santa Ana clinic has two armed sheriff’s deputies on guard during work hours--but they are there because the neighborhood, along 17th Street near Bristol Street, is regarded as a high-crime area.

Warning Buzzers

The county’s seven other out-patient clinics are “wide open--there’s minimal security,� Barton said. The Fullerton and Anaheim clinics do have a warning buzzer in some, but not all, offices; otherwise there are no alarms.

But working with or without guards and alarms, workers say they have learned through experience to treat each client with caution.

They speak of counseling clients with the office door open so neither the worker nor the client is “trapped.� They say they alert co-workers to walk frequently past the door when they are counseling a difficult patient.

Veteran social workers Kott and Aurora Young say they wear comfortable clothing so they can run from a client if they have to. “We dress so we can move--loose clothing and not real high heels,� Kott said.

They and other workers also speak of learning to stay calm, to let an angry patient “ventilate.�

Always, they say, a therapist must be alert to the patient’s mental state, because to relax and daydream can be dangerous.

‘You Could Lose a Finger’

Working in county mental health is “like being in a factory job where if you don’t pay attention you could lose a finger,� psychologist Foust said.

Agreed psychologist Douglas Schiebel: “The key element is to be very aware of who’s in the waiting room, be open to cues of agitation. The most fatal mistake is to ignore someone who is agitated. That will push them over.�

But it is hard to stay cool when the patient in front of you is also threatening to kill you, clinical social worker Ralph DeMarco said. “You have your stomach churning. As a professional, we often practice denial--that this is not going to happen.�

Psychologist Edward Oliver recalls one street-wise patient who sat down in front of him and said: “What do I have to do to get put in a long-term hospital--kill you?�

“I think I just kept talking to him,� Oliver said. “I put him in a board-and-care home.�

Confident About Safety

Ironically, confidence about safety was expressed by several workers in the county’s emergency hold facility, which is for patients who are homicidal, suicidal or so disordered that they must be legally detained. But then, these employees work in a locked ward where they can place a patient in restraints or inject calming medications, whether the patients agree with that or not.

“I think it is pretty safe,� said nurse Barbara Murillo, service chief of the unit. “Not that we let our guard down for a moment.� Murillo said she continued to work at the unit during a recent pregnancy, and “I did my share of holding feet, holding arms� when patients were placed in restraints.

One of the most dangerous situations, many workers said, is outside the locked unit and outside the clinics, during field evaluations.

In this situation, one or two mental health workers respond to a report that someone is deranged--and might need to be hospitalized. (Under Section 51-50 of the state Welfare and Institutions Code, a person can be hospitalized against his will for 72 hours if a designated mental health worker declares him “gravely disabled� because of a mental condition, or a danger to himself or others.)

Because calls to evaluate suspected “51-50s� can be unpredictable, the workers often call police to back them up. But sometimes they are on their own.

Brandishing a Tire Iron

Some of the most dramatic accounts of abuse, threats and even attacks on mental health workers come from field evaluations. Kott was menaced with the butcher knife on an evaluation. Schiebel once answered a call at a “lovely home� in Laguna Hills and discovered the distraught homeowner inside, brandishing a tire iron.

Tony Giusti, a nurse who works out of the Santa Ana clinic, counsels patients but also performs most of the clinic’s field evaluations several days a week.

After doing this for 3 years, he said, he doesn’t think the work is that dangerous. Still, he acknowledged, “when I was a rookie in this field, bad things happened all the time. I’ve had my brains knocked in. I’ve been hit, kicked, bit.�

But these days, Giusti tries to prepare as much as he can for each evaluation. Also, he said, “I know how to remain calm, how to talk in a calm soothing voice� even when clients “get in my face and maintain a threatening posture.�

A young man with a ready sense of humor, Giusti dresses casually for his calls. Although he carries a leather briefcase full of paper work for ordering involuntary hospitalizations, he often goes on his calls dressed in jeans, a T-shirt and perhaps a bulky sweater.

‘Delusional’ Woman

He answered a call last week about a “delusional� young woman at the main courthouse in Santa Ana.

The woman, a blonde with dirt-smudged bare feet, was sitting near a county information kiosk. She had been passing notes to county marshals that said: “God has his own timing.. . . The reason for fear God is the perfect.�

The marshals and Giusti didn’t think the notes made any sense.

Giusti wanted to talk to the woman to determine whether the rest of her life made sense. “Sometimes as we know them more, they get a little more flaky,� he said.

The blonde laughed and talked freely to Giusti. She said she had just gotten out of jail and was waiting for her husband’s attorney to meet her. She said she could have $100,000 cash if she wanted it. Yes, she was sleeping well. No, she didn’t want to see a doctor, she said, explaining: “Today’s food technology is going to be tomorrow’s doctor.�

Bed in Shelter Offered

Giusti was joined by another mental health worker, Wilbert Jacobs, who offered the woman a bed in a nearby shelter. She accepted, then suddenly walked away from them, hopped on an escalator and disappeared.

Jacobs and Giusti debated whether she was sick enough to be held in the county emergency unit. Jacobs didn’t think so. But Giusti thought she was getting “more grandiose� in her thoughts the longer she talked. He and Jacobs found the woman again as she emerged from an upper-floor restroom. Now, however, she wasn’t interested in the shelter; she was determined to wait for the attorney.

Giusti made his decision to hold the woman after calling the office of the attorney she had named and learning from an office worker that the lawyer was not coming for her.

“I’m going to go ahead and pick her up,� Giusti said.

To head off a struggle or an attempt to flee, Giusti alerted the county marshals that he was going to hospitalize the woman, then asked her to step over to their booth. When she obediently walked into a small office inside the kiosk, a marshal stepped in front of the door, blocking it. Giusti informed her: “At this point you are not free to leave.�

‘I’m a Free Person’

The woman rebelled. “I’m a free person and I don’t take drugs,� she said angrily.

Giusti began quietly calling for an ambulance and filling out his 51-50 forms as the woman, resigned to being detained, sat quietly in the marshal’s office.

“We initially tried to get her some shelter but as we stayed with her longer, she kind of deteriorated,� Giusti said. He called her “gravely disabled� because she was barefoot, had no way of obtaining food and shelter, and had “grandiose� thoughts.

The young woman was silent as a marshal led her to a waiting ambulance. But as she climbed aboard a stretcher, she yelled at Giusti, “You guys ripped me off!� and then cursed him.

Giusti merely shrugged. “I’ve been damned to eternity. It’s the third time this week. She’s not happy but she handled it better than most people do.�

‘INCIDENTS’ WITH PATIENTS

Officials from Orange County Mental Health Services reviewed the 227 special incident reports filed in the last 2 years and found that 6 involved staff injured by patients:

Feb. 18, 1987: Patient at (a Fullerton) board-and-care home became violent and slapped person in face, threatened three other people.

March 18, 1988: Inmate sitting in hall outside Mod O (a section of the Santa Ana outpatient clinic) waiting to be moved to a new location. Senior nurse approached him, leaned down to talk to him and the inmate attacked her.

July 4, 1988: Client stole money from another client ($2). When confronted by the (Santa Ana) board-and-care operator, the client attacked (her) with an 8-inch knife and cut her on the buttocks. She declined medical attention for her wound.

Sept. 30, 1988: Patient became angry in course of session with psychologist (from the Mission Viejo outpatient clinic). He got out of his seat, took the psychologist’s attache case from a chair and smashed it against the office window, shattering the glass. He then used the attache case to knock plants, papers and the telephone off the psychologist’s desk. After that, the patient went toward the psychologist menacingly, attache case still in hand. A scuffle ensued and the attache case was knocked from the patient’s grasp. After that, the patient ran from the office. In the course of defending himself against the patient, the psychologist’s right wrist was injured.

Feb. 6, 1989: A woman walked into the (Laguna Beach outpatient) clinic with a male companion . . . and into the secretarial area. She stated, “This is for McKray� and tried to hit me. I deflected the blow with my left arm and she hit my left eye. She tried to strike me a second time and I also deflected that blow and instructed another secretary to call the police. At this point, she and her male companion turned and left the building. She was screaming obscenities at me and got into a vehicle and left.

April 1, 1989: Patient was being transported from UCI Medical Center to Orange County Evaluation and Treatment Services (the county’s emergency psychiatric unit in Santa Ana) by Morgan Ambulance. The patient was on (a legal hold) as “Danger to Others.� Morgan Ambulance attendant stated that the patient hit the female attendant in the face and kicked her in the stomach, then AWOL’d from the ambulance unit (in Anaheim).