Mental breakdown

WATERBURY, Vt. -- When federal inspectors emerged from Vermont's tiny state mental hospital this summer, they described conditions that can best be called archaic.

Patients paced the halls, or sat in isolation, while staff members ignored them. One woman had not bathed in more than four months. A man had not had his psychiatric evaluation updated since he was admitted -- in 1980. When night came, patients on one ward were ordered to bedrooms that were locked from the outside, with no access to bathrooms.

During the review, the situation got worse: Within a span of six weeks, two patients committed suicide in their rooms. One, a 19-year-old woman whose treatment plan specified that she be stripped of her shoelaces, hung herself with a shoelace, according to an advocate who had represented her in grievances against the hospital.

The revelations, shocking anywhere, came as a particular surprise in Vermont, a state much admired for its progressive mental health policies.

Among New England states which embraced the idea of removing mentally ill people from institutions, Vermont emptied its state hospital more quickly and more completely. Vermont boasts one of the nation's most sweeping mental health parity laws, which requires insurance companies to cover mental illness and substance abuse as fully as physical illness. Most remarkably, doctors and consumers seem to agree on the thorniest civil rights question in mental health: Patients in Vermont always have the right to refuse medication, even when they're committed to the hospital.

In his run for president, former governor Howard Dean moved early to stake out the territory of mental health for himself, delivering a speech Sept. 12 that promised "real solutions to the mental health care crisis" and holding up the Vermont system as a model.

But the state's neglected mental hospital shows the limits of the Vermont success story. Last month the hospital lost its right to collect an annual $700,000 in funds from Medicaid and Medicare -- a rare sanction that was brought against only one psychiatric hospital in the country last year, of 477 that receive the funds. The small community of mental health activists and providers here found themselves examining the old shared dream that the state hospital would no longer be necessary. In the end, they say, what happened was that the most seriously mentally ill patients had fallen off government's radar.

"It's one of those attempts that never went as far as it should go. It clearly didn't close the hospital," said Ed Paquin, a former legislator who is now director of Vermont Protection and Advocacy, which advocates for mental health consumers. "What was left came off everybody's front burner," Paquin said. "It was not right to forget about it when we did."

In 1995, Governor Dean announced that the state hospital would be closed for good within two years. The red-brick campus was a potent reminder of a past when patients spent days in straitjackets; in a 1990 survey ranking Vermont as having the nation's best state mental health system, the Public Citizen Health Research Group said the state had "designated itself as a national experiment," discharging patients from the hospital "with an enthusiasm bordering on evangelistic fervor." The hospital population had dwindled from 1,300 to an average of 50 patients at any given time.

But in the eight years that have passed, that number has stayed virtually unchanged.

The 50 who are left represent the most seriously ill of Vermont's population, about a third sent for forensic examination after being accused of a crime, and the rest judged suicidal or dangerous. They range from patients with personality disorders who make repeated attempts to hurt themselves to patients who suffer delusions and hallucinations, said Susan Besio, Vermont's commissioner of developmental and mental health services.

All are in the hospital against their will. But one right they do have, under Vermont law, is to refuse to take psychiatric medication. Typically, between 10 percent and 20 percent of them, or five to 10 patients, are refusing to take medication, Besio said.

Marsha Kincheloe, who retired from the hospital as director of nursing two years ago and coauthored a history of the hospital, said federal surveyors had always been skeptical of patients' right to refuse medication, but that noncoercion worked well while she was there. During daily activities, staff could gradually gain a person's trust, talking over the resistance to taking drugs. When they changed their minds, Kincheloe said, it marked a sincere effort.

"I really think it's better for patients to choose medication, and that may mean working at it for a year or eight months," she said. "None of us would want to be tackled to the floor and injected with something."

Years of state budgets, anticipating the hospital's closure, channeled money to community services instead. The nursing staff dwindled and the psychiatric technicians, who had increasing authority over the wards, were the lowest-paid people in state government, Besio said.

This summer, in a scathing report, surveyors from the Centers for Medicare and Medicaid Services charged that patients were not receiving treatment of any kind. A surveyor interviewed "Patient D," who appeared "distinctly paranoid." The patient's treatment plan did not include antipsychotic treatment, because the patient had refused medication, but instead included such limited goals as "persuade patient to release old psychiatric information" and "verbalize an understanding that the findings of his neurological evaluations do not support heavy metal poisoning."

Therapy sessions were canceled for lack of interest, as patients paced the halls or sat alone in their bedrooms.

Xenia Williams, a 54-year-old activist and mental health worker who has herself been committed to the hospital several times, said she spent her days at Vermont State Hospital "watching pigeons come and go from the roof of the south rotunda." Other patients did the same, she said. Refusing to participate in group therapy, anger management, or other scheduled activities was "the only way they can assert their human dignity," she said.

Meanwhile, staff often refused to befriend or speak with patients, giving them a sense of profound rejection, she said. "[Staff] would sit there playing cards all day while we wandered around forlornly," she said. "Not surprisingly, I got a command hallucination" -- an imagined voice giving orders -- "to tip over the card table."

When staff were unable to use medication to control behavior, they used physical restraints, said Paul Poirier, of Vermont Protection and Advocacy. Often, these means were used against the small group of patients refusing medication, typically diagnosed with personality disorders. The woman who hung herself in September was one of these, and had undergone 134 seclusions, restraints, individual supervision, or involuntary medication treatments since Jan. 1, said Poirier, who represented her in grievances against staff.

Besio said she could not comment on the case because of patient confidentiality.

"We prefer not to use involuntary procedures," Besio said. "If something like that occurs around a patient, it's certainly an extreme. It is in no way the norm."

Last week, Vermonters were struggling to square their ideology with the reality that state authorities still need to lock mentally ill people in an institution -- and that they will continue to do so indefinitely. Peter Van Vranken, who was Dean's health policy adviser when he was governor, said he "really [doesn't] have an answer" to how the hospital was allowed to deteriorate.

"During the Dean administration, we were focused absolutely on community-based care," Van Vranken said. "We were attempting [to eliminate the state mental hospital entirely], but it just didn't work out that way."

Already, Governor Jim Douglas has included a 21 percent increase in funding for the hospital in the 2004 budget, and numerous staff positions have been added. Advocates have pushed plans to add peer counseling or trauma counseling for patients who, they say, are not now treated for their histories of physical or sexual abuse. In January, federal inspectors will return to determine whether to reinstate Medicaid and Medicare funds.

There has been no talk of challenging the right to refuse medication within the hospital. As an opponent of coercive treatment, Besio said it is strange to find herself defending the existence of a hospital at all.

"We're down to the core where everybody has had their rights abridged," she said. "That's kind of the microcosm of that issue."

But, said one advocate, if there's one lesson to be drawn from this summer's revelations, it's this: Ignoring Vermont State Hospital won't make it go away.

"You can't let something slide just because your goal is pushing you in the other direction," said state Representative Anne Donahue, a Northfield Republican who is a member of the group Vermont Psychiatric Survivors. "We all let it happen."

Ellen Barry can be reached at barry@globe.com.