Many psychologists would have thought twice about stepping in to lead St. Elizabeths Hospital in 2007. The historic mental health facility was in dire disrepair and under federal investigation for numerous lapses in patient care, including inappropriate treatment plans, excessive use of restraints and dangerous living conditions.
But Patrick Canavan, PhD, accepted the challenge. He was actually coming home to the place where he started his career as a forensic psychology intern. He was shocked by the hospital's conditions.
"We didn't have enough nurses. We didn't have enough physicians, and I couldn't recruit people," he says. "They didn't want to come here and bank their reputation on ours."
It didn't help that the buildings were falling apart. Established by Congress in 1852 as the U.S. Government Hospital for the Insane, the facility had sprawled to include dozens of buildings, all sorely neglected. When Canavan took over, more than 400 patients were living in eight buildings that were rife with peeling paint, urine-stained tiles and closed corridors that were beyond repair. Plastic sheeting covered some windows, and water pipes dating to the 1870s frequently burst in winter. When Canavan visited the medical records building, an employee told him to wear a filter mask because heavy rains had triggered a ceiling collapse and a massive mold infestation. "The facility was just awful," he says.
Now, five years later, St. Elizabeths is housed in a cutting-edge campus built with $143 million in D.C. government funding. The 293-bed hospital is making progress on a 2007 settlement agreement with the U.S. Justice Department over civil rights violations for inadequate patient care, and Canavan hopes to have all of the settlement terms met next year. He also is pursuing accreditation for the hospital and compliance with a federal accounting agreement over allegations of Medicare billing fraud dating to the 1990s.
"Organizational change really requires getting people to work in a particular direction for a common good," he says. "It's about helping people adapt and changing human behavior."
From psychologist to sewer ‘rat expert'
After receiving his PhD from the Illinois School of Professional Psychology in 1995, Canavan worked at St. Elizabeths as an intern and clinical administrator in the hospital's forensic division, where patients are referred from the criminal justice system. St. Elizabeths — which takes its name and missing apostrophe from the 17th-century land grant where it is located — was transferred from the federal government to the D.C. Department of Mental Health in 1987.
"I always thought the connection between psychology and the law was very interesting," he says. "There is a clear benefit to society through harm reduction, risk management and care for very sick people."
Canavan became restless after five years at St. Elizabeths, and he was intrigued by a managerial training course offered by the D.C. government and George Washington University. After completing the program, he was hired in 1999 by then-D.C. Mayor Anthony Williams to serve as a special assistant working with health and human services agencies to implement some of the mayor's campaign pledges, including a war against rats.
The city had been overrun with vermin, so Canavan organized a "rat summit" that was attended by more than 700 people and dozens of reporters. After an interview at a local news station, Canavan's brother called to tell him about the caption under his televised image. It didn't mention clinical psychologist or special assistant. It just said "Rat Expert."
"The rat summit was my claim to fame, which was really embarrassing," Canavan says with a laugh. "Why do rats have anything to do with psychology? You have to change human behavior to deal with rats and get people to put trash in containers. Humans have to change. It's not really about the rats."
In 2000, Canavan became director of the Neighborhood Services program and brought 16 local agencies together to address neighborhood concerns about health, crime and safety. "Doing that job, I learned every agency in the city, including where they were weak," he says. His background in psychology helped him analyze complex problems and use behavioral skills to win over skeptics and squelch turf battles. "It was really about changing big organizations and getting them to work together," he says. "Part of it was dealing with personalities. Like in social psychology, I was trying to get people to consider a larger goal that they could buy into."
After Canavan spent five years as director of the D.C. Department of Consumer and Regulatory Affairs, then-D.C. Mayor Adrian Fenty asked him to lead St. Elizabeths in 2007. The Justice Department investigation, a lack of leadership and the crumbling infrastructure had demoralized the staff, Canavan says.
"A lot of these people had been my teachers or supervisors, and they taught me what was right in psychology and how to treat people who are seriously mentally ill," he says. "Even though the buildings were falling down around us, the core staff was still very strong."
Canavan says the managerial skills he honed while working in D.C. government helped him tackle the long list of problems cited in the Justice Department settlement. "In the last 15 years, I have established myself as the change guy. I'm the fixer," he says. "The settlement agreement itself became a road map of what to fix."
‘One hospital' culture
One of Canavan's first goals at St. Elizabeths was to unite two distinct groups of patients who rarely met, forensic patients and civil patients. As an intern, Canavan worked with forensic patients who were referred from the criminal justice system for pre-trial mental health evaluations or treatment following a verdict of not guilty by reason of insanity. At that time, forensic patients were isolated from civil patients, who had been referred or committed for treatment by themselves, family members or social services agencies.
Canavan instituted a "one hospital" policy that grouped most patients based on their treatment needs, not where they came from. "My philosophy is we're a psychiatric hospital. We're not a jail or a prison. Clinically, I want people with more intensive needs to be housed together," he says. "That was a culture clash for the staff. People said, ‘These forensic patients are dangerous. They are sociopaths.'"
Pre-trial forensic patients and other high-security patients are housed in the Intensive Housing Unit. Forensic patients who have made progress in their treatment are often housed with civil patients in the Transitional Housing Unit. (The latter group includes John Hinckley Jr., who has been a St. Elizabeths patient since 1982, when he was found not guilty of a assasination attempt on President Ronald Reagan by reason of insanity.)
The new hospital has many features designed for patient and staff safety. In a residence section, the nurses' station has a clear view of all of the hallways, eliminating blind corners that could create security risks. Most patients now sleep in small dormitory-style single rooms, and group bathrooms were replaced with private bathrooms because assaults and other incidents had occurred in large bathrooms in older buildings. "In a mental health setting, privacy means that you're able to have time to rest and recuperate," Canavan says. "You have some private space in an otherwise very traumatizing life."
After the Justice Department cited an excessive use of seclusion and restraints for combative patients, hospital staff now talk with patients about triggers for violent behavior and what actions could help avoid them. Less than 1 percent of patients are now restrained or secluded, according to monthly statistics. "Any time that we have to seclude or restrain somebody, it's a treatment failure," Canavan says.
Canavan also has strengthened the hospital's residency programs in psychology, psychiatry, dentistry and chaplaincy. The psychology program, one of the oldest in the country, was on probation for inadequate supervision and instruction, but it is now fully accredited by APA. The hospital has 27 psychologists and 11 psychology interns on staff.
The hospital seeks to mirror life outside the hospital walls by having patients leave their rooms for "work" in the Therapeutic Learning Center, in a separate area of the building where patients receive various forms of treatment, including cognitive behavioral therapy, art therapy, music therapy, recreation therapy, substance abuse treatment and vocational rehabilitation. All patients go to the center unless their treatment team has given a specific reason to exclude them.
A gymnasium with a basketball court offers a place for exercise and a means of engaging many forensic patients, who often are young men who have never previously received mental health treatment, Canavan says. A general store offers clothes and other goods that are rewards for good behavior or other accomplishments. A small "comfort room," equipped with bean bag chairs and hand-held massagers, provides a respite for stressed patients because Canavan wants them to face their emotions, not retreat to their rooms when they feel overwhelmed.
Canavan's foremost goal for patients is to reintegrate them into community life as soon as possible. "I believe the act of being in a psychiatric hospital is traumatizing," he says. "I want life in the hospital to mirror what happens in the community as much as possible."
Brendan L. Smith is a writer in Washington, D.C.