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Friday / October 30.

Dr. Kevin Huckshorn on Transforming Forensic State Hospitals with Evidence-Based Humanity

Bridgewater State Hospital in 2016

Kevin Huckshorn, Ph.D. MSN, RN, CADC, was vacationing on Sanibel Island in 1992 when she received a call from her boss that she needed to go to Quail Ridge in South Miami, Florida, which, two days prior, had been slammed by Hurricane Andrew. She hopped in the car and headed southeast toward the Keys. As Dr. Huckshorn got into southern Dade County she took in the damage. There were no street signs or functioning lights. Palm trees had been stripped and stood like large toothpicks. Dr. Huckshorn grew up in Florida and was familiar with the havoc hurricanes can wreak. Even so, she found the aftermath of Andrew shocking. She managed to get lost, unsure of the city’s limits, and her only form of communication was a shoebox-sized mobile phone that wasn’t getting reception. “Eventually, I found a service center next to what had been a library but was now a massive two-story-high pyramid of twisted, wet books.” The structure itself, she says, had been peeled back by the storm like an opener taken to the lid of a tin can. 

At the time, Dr. Huckshorn was the nurse consultant for Florida’s state psychiatric hospitals and would drive in a “massive state-long loop” from one state hospital to the next to check in and work with staff to improve care. For several months after Andrew, she focused her energies on helping the Quail Ridge community and the Army officers in whatever way she could, including water runs and setting up tent psychiatric walk-in clinics. What struck her was the resiliency of the community. “People’s survival and helping instincts kicked in; they were focused on the good of the group instead of the individual. It was like watching the human spirit in action.” 

It’s this humanity that continues to inspire Dr. Huckshorn today. She’s known in the mental health community as a hospital fixer, taking hospital facilities on the cusp of losing certification, or worse, and breathing new life into them. She does so by infusing psychiatric hospitals and jails with evidence-based, person-centered practices like Trauma-Informed Care and seclusion and restraint reduction. In 2017, that meant heading to Bridgewater State Hospital in Massachusetts, a state facility that started as an almshouse in 1855 and then, later, became an infamous psychiatric corrections facility. For years, it had the reputation as the harshest state hospital in the United States and found itself the subject of Frederick Wiseman’s 1967 documentary Titicut Follies, which highlighted the abuses and illegal commitment of patients that took place within its walls. The Massachusetts Superior Court banned the film from general public viewership until 1991, citing that it violated patients’ privacy, and ordered that all copies be destroyed. Later, in appeal, the court allowed certain people like doctors, social workers, teachers, and lawyers to view it for educational purposes. 

When Dr. Huckshorn entered Bridgewater’s doors half a century after the documentary was released, she was part of a team tasked with transforming the facility from a prison to a hospital. In this case, she points out, the hospital was, in fact, a corrections facility, so it’s no surprise that it was run one like one. Just like a state’s mental health system is different from all others, so too are state psychiatric hospitals. That said, for numerous reasons, including limited finances and the red tape of bureaucracy, some didn’t develop at the same clip as the rest of the mental health field. For the most part, notes Dr. Huckshorn, large psychiatric institutions were erected in small communities, becoming the primary employer and protected by local elected officials as an economic lifeline for their communities. For a long time, says Dr. Huckshorn, many state psychiatric hospitals were insulated and resistant to change. As time slipped forward, there were evidence-based practices that desperately needed to be integrated into these hospital systems, including those designed to decrease injuries to staff and patients. Having been, to varying degrees, stagnant, some state civil and forensic hospitals suddenly found themselves in jeopardy, needing to update their policies and practices but without the financial or academic resources to do so. 

In other instances, Dr. Huckshorn says it’s more a case of bad luck and, again, the inability to make rapid change. “I could be the best housekeeper in the world, but if my mother came to visit unexpectedly, she would find dust. It’s that way too when a federal agency walks into a facility that’s not expecting them.” She says that shutting down a state hospital is like putting a spoke through the mental health service system wheel. “It will entirely stop turning.” It’s when a hospital is at risk that Dr. Huckshorn and her colleagues at Wellpath come into the picture. She notes that how it begins is formulaic: Wellpath wins a bid or receives a call asking them to take over a hospital in trouble. For example, the hospital might be in danger of losing its Centers for Medicare & Medicaid Services (CMS) certification. Dr. Huckshorn’s personal goal is to address the science to service gap and bring humanity into any facility she enters. 

In 2017, the Bridgewater facility housed 275 men with serious mental illness. Many of the men, says Dr. Huckshorn, had experienced horrific trauma and committed serious crimes when they were psychotic. They were arrested and put in Bridgewater, often without much treatment. “It is difficult to provide comprehensive mental health services in prisons and jails, and people can just get sicker and sicker. The Department of Corrections isn’t trained to treat people with serious mental illness.” When Dr. Huckshorn and her Wellpath colleagues went to the facility, they found it was entirely locked down, and people spent most of their time in their wards or cell. “All of the patients had a cell with big clanking doors that would lock automatically. The facility was staffed by uniformed correctional officers who carried batons, and patients had to wear Department of Corrections clothing. There were few activities, which most patients couldn’t attend anyway, and visiting hours were restricted.” Because the culture was correctional, if a person didn’t follow a guard’s directive, they could be put in seclusion or restraint. It didn’t matter if they were experiencing psychosis. Dr. Huckshorn points out that correctional institutions are designed to contain and control people with safety as the sole priority, not treat them or help them recover. “It was simply the wrong fit for people struggling with severe mental health challenges.” 

At Bridgewater (pre-Wellpath), rigorous debriefings did not take place when the officers did a seclusion or restraint, and patients had few rights and fewer means of recourse. Dr. Huckshorn and her colleagues immediately updated the facility’s mission, implemented a hospital patient bill of rights, closed the seclusion and restraint ward, and brought in behavioral health staff. “Even the security staff we hired were behavioral health technicians.” Wellpath set out to create a culture shift, eliminating uniforms and including therapy dogs in the facility’s programming. The healthcare provider also rebuilt the entire infrastructure, from electronic medical records to peer support, and included patients and families in the process through advisory councils, giving both a seat at the table. There were changes to the building that were needed as well—before Wellpath took over, the facility didn’t have air conditioning, which on hot days, made it upward of 94 degrees inside the hospital. There were no windows to open. Instead of isolation, patients’ days began to be filled with group meetings, exercise, and social gatherings. “We started to get to know the patients, and they were mostly just regular people, albeit with big challenges. What’s tragic is that many committed their crime when experiencing their first break or when they’d become grossly psychotic. Some didn’t remember what they’d done. Others did and were devastated by it.”

Changing a facility’s culture is an ongoing process. This is particularly true at Bridgewater, where many patients spent time in prison beforehand and were exposed to a lot of violence, which carried over to the facility environment. “We’ve been able to reduce seclusion and restraint by roughly 94-95%, but it’s been a struggle to eliminate it entirely.” To address the issue, and for overall wellness, Dr. Huckshorn says staff teach patients coping skills and emotional self-regulation. Yes, the goal is to improve people’s quality of life, but not in a paternalistic way. She says that trauma-informed, person-centered care gives patients a choice and a voice, empowering them to make their own decisions. This approach is also so valuable in helping these individuals learn how to manage their emotions, make better decisions, and be more successful when they re-enter the community as some do. Using the time with people held involuntarily, for any reason, is time that should not be wasted; hospitals, jails, and prisons must offer services that can transfer to the community, whether medication-assisted treatment initiation or better coping skills. 

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) has stated that Trauma-Informed Care is a critical element in closing the gap between “what works and what is offered” in treatment and recovery and that trauma-informed, whole-person healthcare must be made the expectation in all systems of care for people with serious mental illness or serious emotional disturbance. Dr. Huckshorn says that forensic hospitals throughout the nation are moving slowly toward these evidence-based practices, but standardization is still lacking. “It’s not yet the norm. If you broke your arm, you’d expect the same quality of care at any of your nearby hospitals. That isn’t yet true in behavioral health.” She says the tipping point is on the horizon as leaders take note of successes. Kindness and caring can seem like elusive concepts and whole-person, evidence-based practices can feel slippery and intangible, but hospital administrators are witnessing how compassion fuels positive change—not just for patients but also for staff. “They see that reducing seclusion and restraint is doable. Change is happening one forensic facility at a time. Shifting culture at first is hard and an upward slog, but, with more champions and resources, there’s a tipping point, and it starts getting easier, and we’ll begin going down the hill instead of up.”

 

Image: Bridgewater State Hospital in 2016