Tuesday Pleasants thought everything was fine on that Saturday in early March. So when she left the Aldi with a handful of groceries and saw the police standing by her car where her daughter, Rachel Johnson, was still in the passenger seat, she immediately thought there was a mistake.

Her 20-year-old daughter has schizoaffective disorder and had called the police because she wanted someone to intervene in a brief disagreement about word choice that she and Pleasants had earlier in the day.

No, there couldn’t be a warrant out for Rachel’s arrest.

The police had shown up to help, and this was all just a big misunderstanding, Pleasants was certain. They were having a nice day, part of a comfortable weekend stay with Rachel’s grandparents in Henrico County. Everything was great.

But then came handcuffs on Rachel and a trip to the magistrate’s office and an arraignment the following Monday.

Suddenly, Rachel was facing a May 31 court date and a Class 1 misdemeanor, which could carry with it up to a year in jail.

It all stemmed from one of the many hospital stays in a psychiatric unit that Rachel has needed since her mental illness set in seven years ago.

When she was a patient at Bon Secours St. Mary’s Hospital more than a year earlier, Rachel struck a behavioral health technician, Vijay Prakash Gideon, on the side of his head and knocked his glasses off, court records state. He then wrestled her to the ground, called for help and restrained her. He went to the emergency room and missed the next day of work. Rachel says she doesn’t remember any of it.

A month after the incident, Gideon filed an assault charge after consulting with his Bon Secours supervisor.

Such a move is rare for hospital staff, even in a line of work the U.S. Occupational Safety and Health Administration says comes with an increased risk for violence.

Statistics aren’t available on how often someone in the hospital for a mental illness is charged with assault by a health care worker, possibly because it doesn’t happen often, most who work in the field agree.

Bon Secours is no different, and assault charges stemming from patient interactions with staff are exceedingly uncommon, said Jim Newton, the hospital system’s behavioral health services administrative director.

“We do all we can to avoid that,” he said. “We’re in the forgiveness business. We take people into our facilities that, if you read their social histories, you would be very put back by some of their misdeeds, and it’s because of their basic psychiatric illness. This is a brain chemistry issue; it is not a moral lapse.”

Though they face a more violent workplace everyday, hospital workers aren’t quick to file charges for a variety of reasons, said Dr. Bruce Cohen, a psychiatrist with the University of Virginia Health System and director of the U.Va. Forensic Psychiatry Residency Training Program, who has studied the subject.

Cohen pointed out that hospital workers sometimes feel compelled not to take the issue to the criminal justice system because medical ethics say they’re supposed to do no harm to the patient. But that doesn’t mean a hospital worker gives up the right to press charges simply because he or she works in a health care setting.

Ultimately, the decision to file a charge rests with the individual who was assaulted, regardless of where the incident occurred.

Rachel has lashed out in the hospital before, Pleasants said. She has hallucinations. She sees terrifying images, voices whisper in her ear. Sometimes, she strikes others out of fear, especially when she’s having a psychotic episode and has to stay at a hospital for a few weeks, as was the case when she was at St. Mary’s in December 2016. Usually, Pleasants said, the hospital staff will let her be alone for a little while until she calms down.

But this time was different, Rachel and her mother first realized that day in the Aldi parking lot. They didn’t find out about the charge until over a year later because the police didn’t have an address on file.

It’s not entirely clear why that day at St. Mary’s was different than other similar incidents. Bon Secours declined to allow a reporter to interview Gideon, who still works at the hospital, or his supervisor, Angela Shibley. Gideon did not respond to requests for comment sent to his Bon Secours email address. The health system also declined to comment on the incident, citing the ongoing investigation.

Pleasants thinks filing charges against people hospitalized by a crisis could cause a chilling effect that makes family members or those suffering from mental illness less willing to seek help when it’s needed. She worries it could happen to people who don’t have the support system Rachel does.

The issue raises a complicated question about competing rights, Cohen said.

What’s more important: the safety of a behavioral health worker providing care, or the treatment of a patient with a serious mental illness seeking help?

But for Pleasants, it raises a more basic question. She has devoted her life to making Rachel happy and safe. She uprooted them from their home in Richmond to move to North Carolina last year in search of a better environment for her daughter.

If Rachel isn’t safe in the hospital, where can she turn when she needs help?

“It makes me nervous that if she goes to a hospital again, can this happen again? Can this happen again?” Pleasants said. “It happened once. Every time she goes to the hospital, are we going to the courthouse to say, ‘Hey, any warrants out for her? Because she’s been in the hospital.’”

‘Beyond scary’

They came for her in the night.

The voices and the tarantulas that filled up the entire wall and the demons standing right in front of her. They had ancient names: Satan and Beelzebub and Baal.

They’d whisper: “Are you dead yet? Are you dead yet?”

Rachel was 13; a little girl who didn’t understand; a model middle school student with an affinity for science. It all seemed so horribly real.

Like hell had come to earth.

Looking back now with a clarity that medication has allowed her, one thing is still real, beyond any doubt in her mind: the fear.

“Horrifying. Petrifying,” Rachel said. “Beyond scary.”

Rachel was experiencing hallucinations because of her schizoaffective disorder, a mental illness with symptoms similar to schizophrenia. She can talk about it now because — after years of trying — her doctors found the right drugs at the right dose a few months ago, and the pills actually work. (“Finally,” Pleasants sighs with relief.)

Now, she has a firmer grasp on reality, and the drugs keep the demons in the recesses of her mind at bay. But the illness still causes her some trouble.

“I don’t hear anything, but I just feel pressure in my skull like I’m always in a panic attack,” she said.

Sometimes, she still has hallucinations, but she can talk through them with her mom. Pleasants can explain that what Rachel is seeing isn’t real, and Rachel will believe her. And if Rachel gets upset, she can recognize that she’s getting angry, remove herself from the situation, and come back later on when she’s feeling better.

That’s a huge change for her. Her trips in and out of hospitals have stemmed from moments like that when Rachel can’t see clearly, when she can only see the devils standing in front of her, when she can only hear their voices in her ear, when the only thing that seems real to her is the fear.

That’s when Pleasants will turn to the hospitals for help.

Rachel has had to be hospitalized about a dozen times in the past seven years, Pleasants estimates. Sometimes, Rachel can think clearly enough to tell her mom she needs to go. Other times, Pleasants needs help from the police because the Rachel she knows doesn’t seem to be in her daughter’s body.

“I can even look in her eyes and say, ‘That’s not my child,’” Pleasants said. “When she’s doing this it’s like, she’s not even seeing my face because of the hallucinations. ... It’s the fear, and I can see it.”

She’s more likely to hit people when the psychotic episodes set in because she’s not seeing the very real person standing in front of her, but some terrifying image, Pleasants said.

That’s what it was like before Rachel went to St. Mary’s in December 2016. She had another psychotic break, Pleasants said, and the hospital was the only option.

Often, the solution to Rachel’s psychosis is to change her medication. That’s what happened at St. Mary’s, and that’s what Pleasants sees as a possible explanation for the assault. She said the hospital had switched Rachel’s medication on Dec. 8, nine days before she’s accused of hitting Gideon.

The drugs can have a huge influence on Rachel’s behavior, according to Pleasants, because her brain is essentially being rewired.

Rachel doesn’t remember the incident, which Pleasants said isn’t unusual when she’s had a psychotic episode.

“But she says, ‘If I did that, mama, I’m sorry, I didn’t mean to do that,’” Pleasants said.

Now, they’ve found solace in not only the new medication that helps Rachel see clearly but also in their new home in North Carolina. Rachel says her providers at Duke Health have helped her make strides in overcoming her disease. And she volunteers on a farm where she gets to work with chickens.

Even though her daughter still has her moments, Pleasants has hope.

Rachel has more of her good days, when she’s not hallucinating and no one would have a clue that she has a serious mental illness — when she’s just a 20-year-old who loves animals and science.

Especially on those days, she’ll talk about going to college. Even while struggling with her mental illness, Rachel graduated from Douglas Freeman High School in Henrico County.

“I believe that all things are possible,” Pleasants said. “Love conquers all. The more I love my child, the better she gets, and through that we have hope — we have hope that one day, Rachel’s going to get better.”

Rachel likes to recite scripture that gives her courage. She does that now, even with the new medication, when she’s feeling uneasy or stressed — like when she’s thinking about the court hearing next month and the assault charge pending against her.

She’ll whisper to herself a verse from 2 Timothy: “For God has not given us a spirit of fear, but of power and of love and of a sound mind.”

A rare occurrence

Some studies show that half of psychiatry residents on an inpatient unit are assaulted at least once during their residency training, said Cohen, the U.Va. psychiatrist.

A five-year review of another, larger state facility showed an average of three to four assaults per day, he added, and yet another found that five times as many assaults occur as are reported.

“It’s fair to say the majority of assaults do not lead to legal charges, but that hospitals over the years have developed protocols to try to help make these decisions and to try to balance legal concerns with clinical concerns,” Cohen said.

It could be that charges often aren’t filed because staff members know the patients have serious mental illness, or because it happens so often the staff are demoralized, Cohen said.

The state hospitals have a policy addressing these issues, said Michael Schaefer, the Virginia Department of Behavioral Health and Developmental Services’ assistant commissioner of forensic services.

In cases when an assault amounts to a felony — if it involves malicious wounding, for example — the state hospital reports the incident to the commonwealth’s attorney.

But for misdemeanors, which is the level at which Rachel was charged, the decision to press charges rests with the individual who was assaulted, whether that be a staff member or another patient. The state hospital reviews the incidents and tries to determine whether the aggression was intentional or a symptom of the patient’s mental state.

“And more often than not, it’s a product of their mental illness,” Schaefer said.

The state does not keep track of how often it files charges against a patient with a mental illness. Any patient or staff member has the right to press charges, “but I’d say it is a fairly low-frequency event,” Schaefer said.

The whole point of the state system, he said, is to decrease the number of people with serious mental illness in the criminal justice system, “when it is safe to do so and when it’s appropriate to do so.”

A 2015 report by OSHA states that health care workers are at an increased risk for workplace violence.

“From 2002 to 2013, incidents of serious workplace violence (those requiring days off for the injured worker to recuperate) were four times more common in health care than in private industry on average,” the report states.

“I don’t know how well it’s known to the lay public, but when we hire employees, we make sure they understand this is a higher risk than working an office job,” Schaefer said. “We try to give employees the skills to de-escalate people ... how to recognize the signs and symptoms of someone who might be at a higher risk of engaging in aggression.”

Newton, Bon Secours’ administrative director, said the health system has a similar process in which it reviews all incidents that result in injury to a staff member or patient. The health system declined to share how often such incidents occur.

When it comes to pressing charges, though, Newton said that decision rests with the individual employee or resident.

“That, really, is an independent, constitutionally driven (decision) for an employee to make,” he said. “Our policy is we’re not going to abridge anybody’s rights.”

It does concern him though, he said, when such events occur. The hospital does everything it can to prevent it — largely by keeping patients safe if they’re likely to lash out as soon as they get to the hospital, he said.

When individuals with a mental illness do end up in the court system, they have the option of pleading not guilty by reason of insanity — the individual acknowledges that they committed the crime, but did not have any control over their actions due to their mental illness.

According to a DBHDS report, the defense is infrequently used and rarely successful. Nationally, it is used only in about 1 percent of criminal cases, and successful only 25 percent of the time. The cases are difficult to track in Virginia, “but it does appear that it is close to the national average,” the report states.

Still trying

Pleasants gets to see Rachel’s real personality shine through the disease more than anyone else. When she sees her daughter — the one who loves science and school and animals — she knows that’s the true Rachel, the one who is not defined by her mental illness.

Will a judge see that version of her daughter, too?

Rachel is friendly with strangers, loves to volunteer on the farm and adores her Pomeranian, John-John.

The rest of the world might be overwhelmed with pity at the thought of people with brain disorders like hers, but John-John would follow Rachel anywhere. He likes nothing better than to sleep, curled up, in her lap.

During a recent morning in Rachel’s grandparents’ home, the little dog walks beside her as she sits down on the couch next to her mom.

“I think I’m gonna die soon,” she says, resting her head on Pleasants’ shoulder.

Pleasants responds calmly without missing a beat, as if they’ve had this conversation before: “No, you’re not,” she says, rubbing her daughter’s leg and patting her knee.

“I’m so tired.”

“I know you’re tired.”

“I’m trying.”

Pleasants rests her head on top of her daughter’s. “I know you’re trying.”

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