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Dozens of patients at Alaska’s only state-run psychiatric hospital have been arrested this year for assaults inside the facility. Is there a better way for authorities to react?

Alaska Psychiatric Institute is located on Piper Street in Anchorage. Photographed Dec. 12, 2019. (Marc Lester / ADN)

Every few days, Anchorage police are called to the Alaska Psychiatric Institute.

They come to Alaska’s only state-run psychiatric hospital for all kinds of reasons: A disturbance, a threat.

But most often they are called to investigate a reported assault by a patient.

Police reports tell the tale: A patient who slapped a nurse. A patient who spun his arms like a windmill, knocking a staffer in the face. A woman who tossed a cup of hot coffee at another patient. A man who head-butted his psychiatric nursing assistant.

A first-of-its-kind review by the Anchorage Daily News of Alaska Psychiatric Institute police call logs, reports and court records reveals how persistently violence unfolds inside the walls of the hospital — and just how often police and prosecutors are called upon to deal with it.

The records also uncover a practice both common and virtually unknown to the public: Severely mentally ill patients at API are regularly arrested and criminally charged for their behavior inside the hospital.

As of Nov. 14, police had been summoned to API 144 times in 2019, at a time when the hospital has been operating far under its capacity of 80 beds. The patient census has not topped 47 this year.

This year alone, dozens of patients have faced a criminal charge for everything from sucker-punching a nursing aide (assault) to tossing a cup of water at a nurse’s station (harassment).

While the hospital has been in crisis this year, it has long been the overburdened linchpin in Alaska’s mental health care system — the only place in the state with a mandate to treat people civilly committed by a judge or ruled too mentally ill to stand trial for a criminal charge. In almost all cases, it has to accept patients it is dealt — some of whom act out through violence.

The police logs don’t capture the complexity of caring for suffering patients who may be psychotic, catatonic, suicidal, aggressive or delusional, and who have mostly been ordered to the hospital by a judge because they are too ill to care for themselves. They don’t illustrate the hard-won victories hospital workers say they celebrate with their patients, like getting a withdrawn patient to get up and take a shower or attend a group meeting.

They do show that the arrests and criminal prosecutions of psychiatric patients come with a cost, both in public resources and in impact on the fragile lives of the Alaska’s most desperately mentally ill people.

The state says the hospital must maintain a no-tolerance policy for violence to protect health-care workers and other patients. API’s written policies explicitly encourage reporting assaults to police.

“Holding people accountable for their behavior is consistent with the Recovery Model of treatment of persons with mental illness and promotes a safe and respectful environment,” states the API policy manual, revised in March.

“Hospitalization does not remove patient rights and responsibilities for societal standards of humane interpersonal behavior,” the handbook says.

Anyone inside API who is hurt is free to contact police and make a report, Department of Health and Social Services deputy commissioner Albert Wall wrote in an email. From there, it’s up to police to make a decision about arresting a patient.

“In API’s experience, no patient has ever been arrested for ‘misbehavior,’” wrote Wall.

The Alaska Psychiatric Institute, photographed Jan. 30, 2019. (Loren Holmes / ADN)

But experts in mental health and the law question using the criminal justice system to punish people who a judge has already found to be “gravely disabled” by their illness and a potential danger to themselves or others.

If a hospital is where people so psychotic or delusional that they aren’t in control of their actions are supposed to go, can they really be held to account for their behavior inside?

The dozens of arrests at API “seem shocking to me,” said Jennifer Mathis, director of policy and public advocacy for the Bazelon Center for Mental Health Law.

People with psychiatric disabilities are often “needlessly incarcerated” for nuisance crimes like trespassing, Mathis said. Psychiatric hospitals — the supposed placement of last resort for the mentally ill — should not act as another pipeline to a criminal record, she said.

“If the response to the behavior that poses a danger is to arrest people, why are they going to the hospital? What is the purpose of the hospital’s treatment?” Mathis said. “This should be a treatment issue, not a criminal justice issue.”

Others see police visits and arrests as a symptom of a complicated problem that hospitals across the country have been grappling with for years: How to keep desperately needed front-line employees safe from violence without resorting to over-drugging, isolating or restraining problem patients.

Hundreds of hours by police

Violence against staff at API has been a well-documented problem. A 2018 independent report found that API was an unsafe workplace for staff, with assaults and worker’s compensation claims much higher than average.

Workers at API are “on the inside without any way to defend themselves,” said Doug Carson, a business agent for the union that represents most workers at API.

To many workers, involving the police seems like the only recourse, said Carson.

And with the hospital under close scrutiny from state and federal regulators, workers face impossible choices every time they go to work, he said: Expect assaults and other behavioral outbursts, but react exactly by the book or risk discipline.

“It’s a tremendous conflict between the two. You want to respect patient rights but at the same time employees deserve to work in an environment where it’s not so dangerous,” he said.

So what should API do with violent patients it is charged to care for?

The state says it is working this year with contractor Wellpath to train all workers in a technique known as the MANDT system to “de-escalate” patients, in hopes of stopping violent outbursts before they start.

The state has “heavily invested” in the training, said Wall.

The hospital already has in-house security guards through the contractor WEKA, though they aren’t allowed to touch patients or physically involve themselves in conflicts in most cases.

Workers interviewed for this story, including psychiatric nursing assistants who spend the most time interacting face-to-face with patients, said they believe the answer to stopping assaults lies in hiring and retaining more staff.

In-hospital arrests are not a new phenomenon at API.

Data provided by the Anchorage Police Department show that police have been called to the hospital between 147 and 213 times per year since 2015. Many of those calls were coded as assault investigations. Of the records reviewed by the Daily News, many assault reports were for patient-on-staff violence, but some were for patient-on-patient violence.

The peak came in 2018, when police were summoned to the hospital 213 times — an average of more than once every two days.

The police activity at API represents a fraction of what officers are called on to deal with at larger hospitals, such as Alaska Regional Hospital, where people in crisis often end up in the emergency room, said Anchorage Police Department patrol division commander Capt. Sean Case.

Officers, who respond to assaults in pairs, might spend a minimum of an hour investigating an assault complaint, said Case. By that measure, the police department has spent hundreds of man-hours on API assaults this year.

The police would “always be willing to sit down with API and discuss potentially how we can reduce the call costs for services,” Case said.

Police don’t always handcuff people and take them to jail when they are charged with the low-level assaults common at API, said Case. Part of the calculus: The suspect is already in a locked facility.

Case said questions about the wisdom of arresting people already found by a judge to be not in control of their actions are valid.

But should police still arrest patients at API?

A no-arrest policy for API patients would mean that police would have to “look at the victim and tell them they’ve entered a job that they get to come to work and be assaulted, with nothing, maybe, to keep them safe,” Case said.

A pedestrian walks on 40th Avenue near the Alaska Psychiatric Institute on Dec. 12, 2019. (Marc Lester / ADN)

‘You don’t want to be prosecuting people for their illness’

Nationally, the issue of charging psychiatric patients with crimes for outbursts during treatment hasn’t been widely studied, said W. Lawrence Fitch, an attorney and expert on mental health and law at the University of Maryland.

If someone was agitated due to psychosis and lashed out, “the thinking would be, in a case like this, you would not press charges unless the injury is really serious.”

“It would turn on whether their behavior was a manifestation of their illness,” said Fitch.

“That’s what ought to matter," he said. “You don’t want to be prosecuting people for their illness.”

After an API patient is arrested, the next decision point rests with prosecutors, who decide whether the case can go forward in court.

Most of the time, the charges are for a low-level misdemeanor “fear assault,” meaning the victim felt fear they would be hurt, or true assault. Those charges land on the desk of Anchorage’s municipal prosecutors.

There isn’t any special rulebook for assaults committed by people at API, said municipal prosecutor Sarah Stanley.

“We consider whether we think we can prove it, and we look at the intent,” as with any other case, she said.

It’s not easy to prove that a person judged gravely disabled by mental illness formed the requisite intent to assault someone, Stanley said.

For this reason, prosecutors often decline to prosecute and the charges are dismissed.

“It’s kind of tough. We want to support the care providers — and at the same time, you can only charge what’s supported by the law,” said Stanley.

Some cases proceed through the slow and expensive machinery of the justice system.

In some cases reviewed by the Daily News, patients arrested at API quickly had their mental competency to stand trial questioned by judges when they acted bizarrely at initial court hearings or attorneys raised flags.

That put the patients-turned-defendants in line for a trip back to the scene of the crime: the Alaska Psychiatric Institute, to be “restored to competency” so they can be prosecuted.

One 22-year-old man charged three times with violent assaults on API staff and other patients this year remains in jail as judges and attorneys debate his mental competency to proceed.

At one point, a judge ordered him back to API for treatment and the hospital refused to take him.

“It is impossible to re-admit (the defendant) at this time,” wrote Steven Bookman, an attorney with the Department of Law representing API. “With the defendant’s history of assault at API within hours of admission, API cannot safely admit him.”

There’s another unintended side effect to getting arrested at API.

If police decide the person needs to be taken to jail, their civil commitment order — the legal authority keeping them at the hospital getting treatment — is legally null as soon as they leave the grounds.

One 35-year-old woman with no previous criminal record was arrested three times at API in 2019, each time for hitting, spitting on or slapping nurses.

The last time, in August, her mom in Eagle River bailed her out of jail, paying $50.

Correction: An earlier version of this story incorrectly reported the job of Capt. Sean Case of the Anchorage Police Department. He’s commander of the patrol division, not deputy chief.

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