I read with great interest the Register’s article of Aug. 18 detailing some of the issues around assaults at Napa State Hospital.

In 1989, I arrived in Napa to begin my new career at Napa State Hospital. At that time, I was assigned to the forensic program which treated mentally ill patients with criminal convictions. It was interesting work, but I left in late 1992 to pursue other opportunities. I returned in 2007 after the hospital had become a mostly forensic facility with a 50-acre secured area surrounded by a 14-foot fence topped with razor wire, and patrolled by a security force of sworn police officers.

Many of the same patients whom I left behind in 1992 cheerfully greeted me upon my return almost 15 years later. It was apparent, despite years of treatment, they were not going anywhere. They had committed serious crimes and the local county DA’s didn’t want them back in the neighborhood, and Superior Court judges were quite aware of this.

Some patients, however, were able to return to their communities, many of them having spent more years in the hospital than if they served prison time for the same offenses.

According to the article, in 2015, there were 1,053 reported patient assaults and 886 staff assaults. An assault can be anything from a shove to a homicide. That’s 1,939 reported assaults and who knows what wasn’t reported. A facility with 1,200 patients that reports over 1,000 patient assaults in a single year could be considered somewhat less than a healing environment and with almost 900 staff assaults might not be the best place to work, even with generous state benefits. Despite the problems, the majority of front line staff including nurses, psychiatry technicians, social workers, rehabilitation therapists, psychologists and psychiatrists, are dedicated professionals doing their best under difficult circumstances.

The patient population is made up of mostly forensic patients, all located “inside the fence.” They fall into three categories. Most prominent is the group of “Not Guilty by Reason of Insanity” or “NGIs”. They were convicted of crimes, but then in a second phase of their trials, were found legally insane, basically meaning at the time of the offense, the perpetrator was unable to determine right from wrong due to a mental illness. The term “insane” is a legal term and not a psychiatric one.

Then there are the “Mentally Disordered Offenders,” usually referred to as “MDOs.” These patients were convicted of crimes, sent to prison, then later diagnosed as having a mental illness, so they are transported from San Quentin or Folsom, or other prisons to Napa State Hospital.

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The third category is the group “Incompetent to Stand Trial,” often nicknamed with the statute number as “137’s.” They have not yet been convicted of anything, but have been arrested and charged. They are often unruly, grossly psychotic, and frequently combative. Yet, medication can be administered involuntarily only after a judicial hearing.

In the forensic hospital, we no longer deal with a system of crime and punishment, but one of diagnosis and treatment. It is a well-meaning system although perhaps, at times, somewhat misguided.

Staff and patients mingle freely on the ward with no specific personal security. It wasn’t until a well-publicized staff murder occurred in 2010 that the hospital police became stationed inside the secured area. It is well known that for staff, working in the prisons is considerably safer because of the much higher level of security for individuals guilty of the same offenses one sees in the state hospital. This has led to migration of professionals, particularly psychiatrists, away from the state hospital to work in the prison system.

From 2007 through 2011, the courts ordered monitoring of the state hospital system to deal with safety issues among others. This led to the “court monitors,” a team of highly paid “experts” who visited the various state hospitals to weigh in with mandatory dictums for the staff and administration served up with gratuitous browbeating. Some ideas were useful, but many demands dealt with burdensome documentation and were arbitrary, onerous, and at times irrelevant.

Of interest, I recall one time during the court monitors’ visit, a crudely fashioned knife was found on the grounds. The monitors were quickly escorted off the grounds for their safety, presumably so they would not have to deal with the reality that the rest of who remained behind dealt with daily.

Fast-forward to 2017. Staff and vulnerable patients are still getting knocked around. The remedies include transferring a patient to another ward, adding goals to the treatment plan, and sending incident reports up the chain of command, and discussing them at meetings.

The majority of patients are not violent, but genuinely impaired human beings who are treated with compassion and dignity by caring staff. The problems and dangers are not of their making, but are inherent in a system that stubbornly adheres to a premise that sometimes fails to acknowledge a dangerous reality.

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Dr. Michael Bartos was Medical Chief of Staff at Napa State Hospital in 2010-11.