by Anne Galloway, www.vtdigger.org(link is external) May 18, 2011 Not long ago the notion of going to Waterbury was shorthand for a journey into the stigmatizing world of mental illness. For decades, the small burg near the posh ski town of Stowe was identified with the sprawling campus of the Vermont State Hospital. At one point, the facility housed about 1,400 psychiatric patients. In the 1970s, as the deinstitutionalization movement took hold and community mental health services became the mainstay of psychiatric treatment in Vermont, the hospital discharged hundreds of patients. By the early 1980s, about 200 patients resided at the facility.Eventually, the Victorian era brick buildings with slate roofed-turrets and stately facades were transformed from psychiatric units into office spaces for departments and agencies of state government.The facility is so enormous it can accommodate the two largest agencies of state government ‘ the Agency of Natural Resources and the Agency of Human Services ‘ plus the Department of Public Safety.While Waterbury is now most often associated with the Ben and Jerry’s Homemade Ice Cream plant on the outskirts of town and the Waterbury State Office Complex, the Vermont State Hospital has never disappeared from the premises. Today, the ‘Brooks’ building houses up to 54 patients at a time.The facility is now located in the back of the complex, mostly hidden from view. The severely mentally ill patients are kept cloistered in what the outgoing executive director of the Vermont State Hospital calls a ‘prison-like’ environment. The unit is small and staff and patients function in very close quarters. Patients are kept in their rooms most of the time. There is no gymnasium, no garden area, no vocational shops, and very little space for family visitation. When a patient screams or yells or slams a door the sound reverberates through the wards unabated.Terry Rowe, who has served as the executive director of the hospital since 2004, is the first to say the facility is ‘as safe as it can be, but it doesn’t have the physical environment you would really want it to have for a relative or a loved one.’Rowe is leaving what she describes as an extremely stressful 24/7 position to take a 9 to 5 desk job in the Agency of Human Services next month (she’ll be managing the child abuse registry).Since 2004, Rowe has presided over the 54-bed facility for the state’s most acutely mentally ill patients during a tumultuous period in the aftermath of two patient suicides at the hospital in 2003. The Centers for Medicare and Medicaid Services decertified the facility shortly afterward and has repeatedly denied recertification of the hospital since (and the roughly $10 million in annual federal funding that goes along with it). The Department of Justice conducted an investigation into the management of the facility in 2006 and found a number of civil rights violations. The department charged that the hospital failed to ‘protect patients from suicide hazards and undue restraint, provide adequate psychological and psychiatric services and to ensure adequate discharge planning and placement in the most appropriate, integrated setting.’Rowe says she has worked hard to make improvements. The hospital was partially renovated; she began inviting volunteers ‘ musicians, dancers, dog therapy providers ‘ into the facility in an attempt to boost morale. Vermont State Hospital. VTD/Josh LarkinDespite these efforts, since Rowe took the $78,000 a year job eight years ago, she has faced a torrent of negative publicity regarding her management of the state hospital. In a recent interview, she said the bad press destroyed the reservoir of good will necessary for the hospital to succeed. Last month, a patient set a fire in one of the rooms with an alcohol wipe, a battery and a piece of tinfoil. At about the same time, hospital staff went to the press with complaints about mandatory overtime.Rowe takes full responsibility for both incidents. She said the fire was handled in a by-the-book response by staff (who immediately put out the flames with a fire extinguisher). The staff complaints affected her deeply. Though Rowe says she instituted an advance voluntary overtime system right away, the rift with her staff forced her to reconsider staying on at the hospital.As for the long-term failure to procure federal recertification, Rowe points to a structural problem that she says fundamentally undercuts the staff’s day-to-day efforts to make the experience at the hospital as therapeutic as possible: The Vermont State Hospital facility is an unhealthy environment for patients.Patients who at one time would have been separated into different units for treatment are now concentrated in a small space. Violent criminals with mental illness share space with elderly Vermonters with dementia and behavioral problems. Patients with anti-social personalities live on the unit with developmentally disabled patients and people with traumatic brain injury, patients with psychosis and people who exhibit self-harming behaviors.The comingling of patients who require different therapeutic treatments in separate psychiatric units into one small space has led to a spiraling series of problems that have plagued the state hospital for a decade.There is the added difficulty of providing patients with sufficient access to the outdoors. The Vermont State Hospital is in a very public location inside the state complex. A road cuts past the yard.‘When I first came here the fences were open and you could see right in at the patients it was almost like a little bit of a zoo,’ Rowe said. ‘People could stop and look at the patients behind a fence.’Individuals in different categories of mental illness require different therapeutic treatments. In the current physical environs of the hospital, it’s very difficult to provide discrete psychiatric therapies, according to Rowe.‘There’s the concentration of those people who are most difficult to treat are now all assembled in one area whereas before you might have had more of those patient types with their own unit,’ Rowe said.Most hospitals, in contrast, have separate floors for different kinds of health needs ‘ an orthopedic floor, cardiac floor, a labor and delivery floor.‘We don’t have that,’ Rowe said. ‘We have all of the different patient needs all on the same unit. When you begin to think of that you realize you have patients who have a propensity toward violence there’s a way of interacting with them that can be helpful but as they’re expressing that violence, what occurs is that the in-patient unit is impacted by that so that staff feel less safe because they know a patient is having an extremely difficult time managing his or her behavior. Other patients are frightened because they see this patient unable to manage his or herself and when you have danger like that on the unit on an ongoing basis it begins to impact the therapeutic environment. I think that most therapeutic environments really rest upon having safety so that you know you have an environment within which you can explore what’s happening inside of you. You can work with people around your symptoms or engage with people therapeutically. When there’s an enormous amount of fear on the in-patient unit, it affects everybody from the other patients and the staff.’The situation, in Rowe’s view, exacerbates violent patient behaviors. The Vermont State Hospital has the highest rate of injury to employees in state government, according to Rowe. The Department of Corrections and the Vermont State Police both have lower incidences of at-work injuries, she said.It’s common for patients to punch, kick or spit at state employees who work at the hospital. Over a two-year period, nearly 200 workers were injured at the facility.Read the Vermont state workforce injuries report‘I actually see that (injury rates) as a significant issue and really I think calls into question broad systemic need,’ Rowe said. ‘We need to think more broadly at who is coming to the hospital, how are patients being provided care in this setting, and is this the appropriate setting for all of these patients.’Though the staff has been trained in conflict de-escalation techniques, she said ‘there are times when a patient and it happens fairly regularly where a patient won’t respond to that and patients strike out at staff members.’A lingering problemThe state Legislature and Gov. Jim Douglas attempted to find a privatized solution to the Vermont State Hospital. There was talk of shutting the facility down and replacing it with services at community hospitals around the state.The Douglas administration pushed for the construction of small facilities associated with private community hospitals, but the $1 million per bed price tag for buildings on the Fletcher Allen Health Care and Rutland Regional Medical Center campuses dashed public support.The Futures Project, as it was called, was a five-year study process. In the end, nothing was built.Every year the state doesn’t take action it costs the treasury about $10 million.Now, eight years after the federal government pulled financial funding for the hospital, the arguments about what to do with the Vermont State Hospital have come full circle: There is talk of building a new $50 million facility with a 50-bed capacity in Berlin near the Central Vermont Medical Center.The Legislature has set aside $2.5 million for a feasibility study and conceptual drawings for a new facility.‘I worry about the fatigue people may have about the Vermont State Hospital and Futures Planning, and I don’t know if we’re really at the end of that discussion,’ Rowe said. ‘People just really want the discussion to be over with, but I when I look at the patients here I think about who is mentally ill in Vermont and how are we meeting those needs in Vermont, be it in the correctional facilities or within the Vermont state hospital or in the community or in the community hospitals and I think about what are those units of care that best serve the different populations that we know have mental illness. I think we have a commissioner and deputy commissioner who are extremely open-minded in understanding these issues more thoroughly but it seems to me that it’s essential that we talk about what the best models of care are to meet those different groupings of need.’Rowe declined to offer a proscriptive solution to the facility conundrum, except to say that she thinks the state’s correctional system needs to be part of the discussion. She suggests that the state could combine populations between the Vermont State Hospital and the Department of Corrections.She also came up with an analogy that compared services offered by private hospitals and state-subsidized mental health care treatments at the Vermont State Hospital with the educational system. In public schools, all-comers are welcome ‘ underprivileged and special needs have equal access to education. Likewise, the state hospital cares for people with the most intractable problems ‘ regardless of cost.‘You see the private education system able to be more selective with the student population,’ Rowe said. ‘That creates a certain environment for those students that doesn’t necessarily exist in the public environment. In some ways it feels analogous that the private hospitals really are selecting who is coming on their in-patient units. And that actually matters then certain patient populations can be served in those settings more effectively than if they had come to our setting or they’re providing a different level of care than what we are providing.’ Anne Galloway is editor of vtdigger.org Photo: Vermont State Hospital Director Terry Rowe. VTD/Josh Larkin.