Psych NP stabbed to death

[allantois]

Didn't see anyone post this tragic story

Nurse practitioner stabbed to death by patient, family says

A family member of June Onkundi said she loved her job as a mental health nurse practitioner. The family member said she was on the job when she was stabbed by her own patient. James Gomes is facing a first-degree murder charge.

www.wral.com

---

Members don't see this ad.

 

[wolfvgang22]

Very sad. Apparently that patient was a felon recently released from prison, but was treated like any other patient.

 

[RomeoNP]

Sober reminder that sometimes this line of work can get very dangerous. She had four kids all under the age of 18, very senseless and tragic.

 

[michaelrack]

Very sad. Apparently that patient was a felon recently released from prison, but was treated like any other patient

Chronic schizophrenic released from prison with no or limited supply of their haldol is a frequent admission at some psychiatry hospitals

 

[annoyedpsychiatrist]

Chronic schizophrenic released from prison with no or limited supply of their haldol is a frequent admission at some psychiatry hospitals

After working in the community health setting for a while, the diagnosis of schizophrenia is used in a very liberal way when the patient decides malingering is a solution to their issue with access to resources. I dont believe a diagnosis till I see it. And on that note, lots of people in the prison system who do have schizophrenia and are never properly diagnosed/treated. I will say that the vast majority of my schizophrenic patients are non violent.

The fact that he was carrying a knife, presented to the appointment, and carried out the murder makes me wonder how much his mental state was impaired vs how much of this is premeditated or ****ty human behavior/antisocial. Granted I havent watched the video yet.

 

[WisNeuro]

After working in the community health setting for a while, the diagnosis of schizophrenia is used in a very liberal way when the patient decides malingering is a solution to their issue with access to resources. I dont believe a diagnosis till I see it. And on that note, lots of people in the prison system who do have schizophrenia and are never properly diagnosed/treated. I will say that the vast majority of my schizophrenic patients are non violent.

The fact that he was carrying a knife, presented to the appointment, and carried out the murder makes me wonder how much his mental state was impaired vs how much of this is premeditated or ****ty human behavior/antisocial. Granted I havent watched the video yet.

Agreed, I used to work in a hospital that got a lot of very low SES individuals, as well as overflow from the shelter across the street when it was full. Less than half the time that I had that in the chart of someone I evaluated, was it an accurate diagnosis based on chart review and the eval itself. No clue in this situation, but I have little to no faith of most MH diagnoses in the patient's chart unless I have evaluated personally.

 

[wolfvgang22]

My patients with Schizophrenia are for the most part very kind people and very vulnerable to exploitation.

The patients that concern me the most re: violence are drug seeking patients angry I won't prescribe their substance of choice and the occasional lifelong criminal that sells drugs and guns. Those guys usually show up discharged from prison with Bipolar and polysubstance diagnoses and undiagnosed cluster B.

 

[whopper]

Often times when severely mentally ill people are released from prison or jail they are just given meds to last a few weeks or possibly nothing at all and left to fend for themselves.

 

[calvnandhobbs68]

Yeah this guy seems to have been "seriously mentally ill" in an antisocial personality disorder way...take a look at his record. Multiple prior assaults against females, once held a knife to a woman's throat and sexually assaulted her, another prior assault against a healthcare worker where he beat the crap out of her.

"July 2006, Gomes was convicted of first-degree attempted rape and second-degree kidnapping. In March 2005, he also tried to rape his coworker with a knife to her throat. In March 2019, he was charged with kidnapping, assault on a female and assault by strangulation and was released from prison only four months ago."

These are the kinds of people three strikes laws were made for.

 

[allantois]

Three strikes? One strike is enough

 

[ObsequiousAplomb]

Yeah this guy seems to have been "seriously mentally ill" in an antisocial personality disorder way...take a look at his record. Multiple prior assaults against females, once held a knife to a woman's throat and sexually assaulted her, another prior assault against a healthcare worker where he beat the crap out of her.

"July 2006, Gomes was convicted of first-degree attempted rape and second-degree kidnapping. In March 2005, he also tried to rape his coworker with a knife to her throat. In March 2019, he was charged with kidnapping, assault on a female and assault by strangulation and was released from prison only four months ago."

These are the kinds of people three strikes laws were made for.

And unless there were actually psychotically-driven motivations for these actions and/or a separate psychotic disorder, it makes perfect sense that someone with that history wouldn't be treated in prison for schizophrenia, released from prison with a prescription, or have any good indication to be seen by that NP.

It's a political issue though, because laypeople hear this story and assume it must mean the psychiatrist in prison messed up and not that this is an incredibly violent person who wouldn't benefit from medications.

 

[comp1]

I can't speak specifically here, but in general...I get very frustrated when antisocial behavior is labeled as "mental health related." The only effective treatment for antisocial personality pathology is strict boundary setting followed by strict consequences. The sort of flexibility and patient autonomy assumptions that are found in general mental health treatment are often actively harmful and lead to these sort of outcomes, albeit not often this severe.

 

[Orgone]

The full details don't appear available, but if the (presumably) clinic had her see this pt alone when he had that history . . . yikes. Come to think of it, I've never received outpt schizophrenic pts directly from prison. I'd be curious to know if they tend to actually send any records of criminal and MH history.

According to the video the attempted rape with a knife to the throat was while he was employed as a janitor at an elementary school. Again, yikes.

 

[randomdoc1]

yes, sounds very antisocial with that track record. And this most recent incident, has a premeditated flavor.

get very frustrated when antisocial behavior is labeled as "mental health related."

I totally agree. Hence it promotes the stigma of misunderstanding the vulnerable population we work with. A population predominantly more vulnerable than predatory and those with active MH diagnoses feeling marginalized and not wanting to pursue care because they don't want belong to that crowd of "those kinds of people." It really gives terms like MDD, bipolar disorder, schizophrenia and more a bad rap. The loudest most attention drawing patients tend to have predominantly cluster b (often poorly managed either due to access issues or patient's own decision) who call themselves these Axis I disorders. I really really hate that.

 

[MacDonaldTriad]

With all of the negative NP feeling on this site, please contain your comments and do not say anything here. This is both scary and sad for all of us.
We should be mindful of dangerousness in histories and forensic profiles. Just using the hair on the back of our necks doesn't work very well. We need to have security and action plans for threats. Not everywhere has ideal security, but we could use what we have more optimally. This will never go away completely. We need to manage risks best we can and be non-complacent about it.

 

[calvnandhobbs68]

With all of the negative NP feeling on this site, please contain your comments and do not say anything here.

Was there some negative NP sentiment on this thread I didn't pick up on?

 

[Candidate2017]

After working in the community health setting for a while, the diagnosis of schizophrenia is used in a very liberal way when the patient decides malingering is a solution to their issue with access to resources.

The fact that he was carrying a knife, presented to the appointment, and carried out the murder makes me wonder how much his mental state was impaired vs how much of this is premeditated or ****ty human behavior/antisocial.

Yes, it's easy to get a psychotic diagnosis. Tell the overworked resident, or lazy prison psychiatrist, you hear voices. Something has to be coded, after all. Then you'll get attention from social workers, nurses, and NPs, all of whom are female. It's a nice break from the usual in prison. This is one of the reasons prison guards have a negative view of psychiatry and don't take real psychiatric issues seriously. The guy is a predatory rapist, so likely he knows how to game the system.

It appears the clinic is a "recovery" center. I wouldn't be surprised if it's a CMHC-funded substance unit, given the guy just got released from prison and is likely on Medicaid. I also wouldn't be surprised if no one told the NP about his history. This is a reminder that large organizations do not care about you (or by extension, your safety). The organization exists to rake in hundreds of millions of dollars from third party payors. If employees get hurt or killed, oh well, the organization has workers' comp. You are responsible for your safety.

My patients with Schizophrenia are for the most part very kind people and very vulnerable to exploitation.

The patients that concern me the most re: violence are drug seeking patients angry I won't prescribe their substance of choice and the occasional lifelong criminal that sells drugs and guns.

The majority of patients are benign. But we shouldn't downplay the significant minority of patients with psychotic/manic disorders who get very violent and irrational when off their meds (hello ED psych). The risk is even greater if past violence, substances, personality, not working, Medicaid, outpatient, and under 55.

I'd make a distinction between predatory sex criminals and career criminals who sell drugs/guns (i.e., illegal businessmen). The businessmen are quite rational and predictable in thought and behavior ("Will this crime benefit me monetarily and is it worth the risk? If not, I'll move on").

I feel new evals who are seeking controlleds are generally fine beyond some yelling and foot stomping. The worst are substance seekers inherited from the clinic candyman, as they view you as taking away "my Xanax". It generally helps to have the scheduler warn them in advance controlled substances will likely be tapered off and they should seek another doctor if they wish to maintain them.

 

[comp1]

Patients with serious mental illness are more likely to be victims of violence than commit violence, BUT patients with serious mental illness are also more likely to commit violence than the general population. We should keep that in mind. That said...it's not super relevant to this event as this guy sounded antisocial as heck.

 

[erg923]

.

 

[singasongofjoy]

Caveat- I have not dug into the details of this case yet. So with that in mind a thought I’ve been wondering is the timeline and chain of communication- in addition to safety protocols. When places are understaffed and everyone’s at their max, having the full context and time for record review before meeting a patient can sometimes get the short end of the stick. I am curious how much general overburden and burnout/understaffing along the links in the chain might have played a role. Anyone who has looked into this in more detail have thoughts?

 

[Stagg737]

I can't speak specifically here, but in general...I get very frustrated when antisocial behavior is labeled as "mental health related." The only effective treatment for antisocial personality pathology is strict boundary setting followed by strict consequences. The sort of flexibility and patient autonomy assumptions that are found in general mental health treatment are often actively harmful and lead to these sort of outcomes, albeit not often this severe.

There's actually a program in Wisconsin (Mendota Juvenile Treatment Center) that uses mostly positive reinforcement with minimal punishment which has been very successful compared to really any other treatment. The idea is that these individuals simply don't learn from punishment and will repeat many of those behaviors regardless of how you punish them, basically psychopaths. It's talked about in a few books like "The Psychopath Whisperer" and is probably the most effective "treatment" for violent offenders. The caveat here is that this program treats juveniles and I'm unaware of similar programs being successful for adults.

Regardless, I would agree that repeated antisocial behavior as the primary problem is not amenable to medication treatment and that trying to treat these individuals as psych patients is a mostly futile endeavor.

 

[randomdoc1]

There's actually a program in Wisconsin (Mendota Juvenile Treatment Center) that uses mostly positive reinforcement with minimal punishment which has been very successful compared to really any other treatment. The idea is that these individuals simply don't learn from punishment and will repeat many of those behaviors regardless of how you punish them, basically psychopaths. It's talked about in a few books like "The Psychopath Whisperer" and is probably the most effective "treatment" for violent offenders. The caveat here is that this program treats juveniles and I'm unaware of similar programs being successful for adults.

Regardless, I would agree that repeated antisocial behavior as the primary problem is not amenable to medication treatment and that trying to treat these individuals as psych patients is a mostly futile endeavor.

Totally. People or even more generally mammals, respond much better to carrots than sticks. Even antisocial personality. Everyone likes a carrot.

 

[clozareal]

There's actually a program in Wisconsin (Mendota Juvenile Treatment Center) that uses mostly positive reinforcement with minimal punishment which has been very successful compared to really any other treatment. The idea is that these individuals simply don't learn from punishment and will repeat many of those behaviors regardless of how you punish them, basically psychopaths. It's talked about in a few books like "The Psychopath Whisperer" and is probably the most effective "treatment" for violent offenders. The caveat here is that this program treats juveniles and I'm unaware of similar programs being successful for adults.

Regardless, I would agree that repeated antisocial behavior as the primary problem is not amenable to medication treatment and that trying to treat these individuals as psych patients is a mostly futile endeavor.

I really wonder what kind of positive reinforcements they use. Don't kids with conduct disorder respond much less to positive reinforcements than those who don't have it? It makes sense that if lack of empathy or concern is a diagnostic feature of this disorder, that consequences won't matter. How does a person understand or feel guilt or know something is wrong when they don't care about others?

I've heard an argument by a forensic psychiatrist that treatment with psychotherapy for antisocial personality disorder is actually more harmful to society because it teaches them to understand others better and they can use that to lie/manipulate more easily.

 

[Jules A]

Really sad news. I wonder what actually transpired. The information might be useful in an effort to avoid similar outcomes. Unfortunately in my limited experience when there was a death or significant injury, except in the jail system where they did a thorough M&M review, the cases seemed to be paid off and swept under the carpet as quickly as they happened.

 

[splik]

I've heard an argument by a forensic psychiatrist that treatment with psychotherapy for antisocial personality disorder is actually more harmful to society because it teaches them to understand others better and they can use that to lie/manipulate more easily.

This has been the conventional thinking, but is specific to adults w/ psychopathy and NOT children with callous/unemotional traits. In addition the thinking on this has been based heavily on a study which included treating (often naked) psychopaths with psychoanalytic informed therapy and LSD had higher rates of recidivism than those not receiving this treatment. Obviously no one is doing this kind of treatment these days!!

mentalization based treatment is being used in the UK for patients with dissocial personality (the ICD-10 term for antisocial PD) and they do have concerns about the potential for such treatment to create more dangerous people if not used carefully. moral reconation therapy (MRT) is a CBT based treatment used is prisons and juvenile settings that has been shown to reduce offending behavior.

So the idea that therapy is harmful to psychopaths has not been validated and the one study which really was the death knell of treatment and showed worse recidivism in psychopaths was very unethical and bizarre treatment that would not be offered today.

We think that treatment of psychopathy has to focus on why it is in their best interests not to behave in antisocial ways. If they cannot see the advantage in doing so they won't. It is probably the case that the chances of success are dire in adults but there is more hope for young people with callous/unemotional traits.

 

[MacDonaldTriad]

Was there some negative NP sentiment on this thread I didn't pick up on?

A lot of it was sky is falling, NPs are ruining our industry and psychiatry is going to hell in a handbasket stuff.

 

[annoyedpsychiatrist]

Given the severity of his prior offenses it is crazy to me that he was ever let out of prison. I mean some people are just genuinely awful with no real redeeming qualities. Im sure he was also receiving disability benefits for his "schizophrenia". The system is broken because we are too forgiving to people like and once they get that magic diagnosis they can attempt to justify all their actions as a result of "mental illness". The average person or politician doesn't understand that sadly and this is why i dont have high hopes that the system will get better.

 

[calvnandhobbs68]

A lot of it was sky is falling, NPs are ruining our industry and psychiatry is going to hell in a handbasket stuff.

Not that I can see in this particular thread.

People can be against NP independent practice and also not think they should be murdered on the job...those are not mutually exclusive ideas

 

[Candidate2017]

When places are understaffed and everyone’s at their max, having the full context and time for record review before meeting a patient can sometimes get the short end of the stick.

Many understaffed places are actually well-funded but purposefully understaffed in the name of more profits.

I am curious how much general overburden and burnout/understaffing along the links in the chain might have played a role. Anyone who has looked into this in more detail have thoughts?

Burnout/understaffing likely has nothing to do with it. Give me a handful of jaded, experienced staff over an army of clock punchers. There's some bystander effect, normalization of mediocrity, lack of ownership, institutionalization, and learned helplessness at play. Perhaps someone versed in organizational psychology can elucidate.

Have you seen employees at large organizations? They are, for lack of a better term, mentally lazy. The admin who makes rules without thought or clinical experience, the secretary who can't answer phones properly, the MA who forgets to input vitals, the out of shape 5 foot security guard who waves everyone in, the psychiatrist who doesn't care to read up on coding, the NP who doesn't care to read up on meds, the SW who doesn't care to read up on therapy, etc. These people are attracted to large organizations because it allows them to shift responsibility to a faceless bureaucratic entity. Widgets, everywhere, they are.

There will be the memos about de-escalation, safety awareness, rape whistles, free counseling for coworkers, etc. But the organization will carry on as usual. No doubt, the blood has been cleaned up, and there is another widget assigned to take the NP's place because billing must go on.

 

[whopper]

Adding to unmentioned teachable comments and I agree with the above.

This is a reason why I don't take people "Fresh off the boat" or so to speak. Here's what I mean.
Some hospitals the second they find a disposition discharge even when the patient is not stable. I've seen it happen. There's a lot of forces pushing inpatient doctors to get rid of a patient ASAP including having to answer and justify hospitalizations to a 3rd party insurance doctor who'll reject hospital stay no matter what even if it's clearly justified.

I've had nightmare cases of hospitals dumping patients to me. When I first opened private practice I had a case where a drunk patient was dumped off at my office literally the first 15 minutes he was legally sober. The hospital pretty much nothing about him other than the minimum required to keep him in the ER. Then they just dumped him off.

What I've done to prevent this bullspit is require the patient themself, not a social worker or nurse to schedule the first appointment. At this time I don't even take new patients unless referred by someone else. While I was still taking patients I made it a rule not to take a new patient direct out of hospitalization unless that patient was to be seen 1 month later. This would force a hospital doctor to make sure the patient was reasonably stable before I took them on as a new patient. I also required all records be sent to me before I even considered the person as a patient.

Despite this I still have problems although with the above safeguards they're much less. I had an existing patient, one for years, be prematurely discharged. She's late-onset schizoprhenia and I had her for hears for opioid dependence that she eventually overcame, graduated off of Buprenorphine treatment, and cyclothymia was only only seeing me every few months for maintenance checkups. She had been stable for about 5 years. While psychotic she physically assaulted people. The second they found out she had an outpatient doctor they pretty much discharged her a day later.

I had to send her back to the hospital the first 5 minutes I saw her again.

 

[Stagg737]

I really wonder what kind of positive reinforcements they use. Don't kids with conduct disorder respond much less to positive reinforcements than those who don't have it? It makes sense that if lack of empathy or concern is a diagnostic feature of this disorder, that consequences won't matter. How does a person understand or feel guilt or know something is wrong when they don't care about others?

I've heard an argument by a forensic psychiatrist that treatment with psychotherapy for antisocial personality disorder is actually more harmful to society because it teaches them to understand others better and they can use that to lie/manipulate more easily.

Splik answered it well, but it's important to keep in mind the program in Madison is for juveniles. As he said, the idea is that with positive reinforcement you can help them understand the benefits to themselves by abiding by social laws and the best outcomes are in regard to the prevention of future violence. From what I understand, the program essentially uses a point system where earning a certain amount of points for X days in a row allows them certain privileges in the detention center. It's not about understanding guilt, it's about teaching them that following certain rules gets them what they want.

Sure, you can make the argument that it teaches them to lie or manipulate, but when the goal is to prevent them from raping or murdering people, who cares if they're a little better at lying? Also, as Splik pointed out, the commonly cited study about therapy being "dangerous" was a situation where the sociopaths were given hallucinogens to try and help them feel appropriate emotions which failed pretty badly in terms of violent recidivism. In subsequent interviews with those patients, one said the LSD didn't teach them how to feel things, just how to imitate and lie about the feelings better.