From 'Enforcer' To Counselor

This story ran in The Courant on October 15, 1998
Will Overton used to be called "The Enforcer."


MIKE PIGNONE, an aide at the Harold W. Jordan Center, talks with a patient on the grounds of the Nashville facility. Recent changes at the center are the result of Tennessee's efforts to minimize the need to physically restrain patients. "If we could do it here, it can be done anywhere," said a Jordan Center administrator.
With 280 pounds of solid Tennessee muscle wrapped around a 6-foot-3 frame, the aide at the Harold W. Jordan Center was called in to help "shuffle" patients -- slamming them to the ground face-down if they acted up or disobeyed. And the 30 mentally retarded and mentally ill patients -- people accused of murder, rape and other crimes -- often disobeyed.

"I used to be a bad boy," said Robert Hall, a short, wiry patient with the energy of a wound rubber band. "I was shuffled about every day."

Not anymore. Behind the Nashville center's locked gates and razor wire a radical turnaround has occurred in the last year. Shuffling is now forbidden, staff has been increased and given intensive training.

Tennessee's example shows that, with strong leadership, the physical restraint of patients can be minimized -- indeed, nearly eliminated -- safely and without exorbitant cost.

"If we could do it here," said Frances Washburn, deputy superintendent of Clover Bottom Development Center, which includes the Jordan unit, "it can be done anywhere."

But the routine and frequently dangerous use of restraints persists elsewhere, even though the solutions are often simple and straightforward: better training, stronger oversight, uniform standards and the collection and sharing of information.

Federal officials and health groups say they are working on it.

The U.S. Center for Mental Health Services has begun a five-state pilot program to collect restraint and seclusion data. The U.S. Department of Veterans Affairs is tracking deaths more closely.

The Joint Commission, the nation's leading hospital accreditation organization, has strengthened its guidelines on restraint and seclusion. And the American Medical Association has begun studying the use of restraints on children.

"Those steps sound pretty inadequate to me," said Dr. Joseph Woolston, medical director for children's psychiatric services at Yale-New Haven Hospital. "This sort of half-hearted patchwork approach will probably do more harm than good by giving an illusion that something is happening when it is not."

So for now, it is left to individual hospitals to find their own way. Those committed to the task illustrate what can be done.

Riverview Hospital for Children and Youth, a state-run psychiatric hospital in Middletown, Conn., uses an intensive training program that emphasizes non-physical intervention when a patient loses control.

"These situations are often chaotic and unpredictable, and without proper training, staffers are just winging it," says Linda Steiger, executive director of Wisconsin-based Crisis Prevention Institute.

CPI, a leading private training company, provides instruction to Riverview workers. The cost is minimal: $895 per person for a four-day program to teach a small number of designated staffers, who then instruct their peers.

Tighter procedures also emphasize that every restraint is a major step -- literally, a matter of life and death.

At Riverview, a staffer is required to constantly monitor anyone in mechanical restraints. That ensures a patient's vital signs remain strong, and provides an incentive to end the intervention as soon as the patient regains control.

At Tennessee's Jordan Center, patient treatment plans that include the use of restraint are, for the most part, rejected. And every use of emergency restraint is investigated and must be defended.

"When forced to go through the self-analysis and justifications, they solve it at a lower level the next time and without restraints," said Thomas J. Sullivan, who heads Tennessee's Division of Mental Retardation Services. "Of course, this requires staff to give up total control."

Emergency restraints are so infrequent now that Sullivan gets an e-mail message every time they are used. He's gotten an average of just two to three e-mails per month since January.

Accountability means staffers share more information and learn from the mistakes of others. Techniques found to be dangerous, such as face-down floor holds and mouth coverings, have been outlawed in certain places as a result.

But tough lessons learned by individual hospitals typically aren't shared with facilities on the other side of town or 10 states away. Each hospital is left to reinvent procedures or learn the hard way -- through the death of a patient.

It doesn't have to be that way.

New York state has reduced restraint use and the number of related deaths by requiring the reporting of usage rates and by investigating all deaths.

After New York required all mental health facilities to say how often they use restraints -- and published the numbers -- the top three users revamped their policies and brought their numbers down.

When it came to deaths, the state used to allow each hospital to decide which ones were questionable enough to report. It was notified of 150 cases over three years. Once mandatory reporting of every death was instituted 20 years ago, the number of deaths requiring further investigation rose to 400 a year.

"When people have a choice in classifying deaths -- with one choice resulting in tremendous scrutiny, the other resulting in none, what do you think they're going to do?" said Clarence Sundram, the former chairman of the independent New York agency that tracks and investigates deaths.

Accountability has produced results. Restraint-related deaths in the past five years have been cut nearly in half as compared with the preceding five years, New York state records show.

Nationwide accountability could accomplish the same.

"There needs to be some kind of state-by-state evaluation to gather comparative statistics and give an annual report to Congress," said Dr. E. Fuller Torrey, a prominent psychiatrist and author.

"Until you embarrass the individual states," Torrey said, "nothing will be done."

The federal government has shown a willingness to intercede on this very issue -- in response to charges that the elderly were being abused.

When the U.S. Food and Drug Administration estimated in 1992 that more than 100 people annually were killed through the use of mechanical restraints in nursing homes, the agency tightened rules on their use.

"We also thought these cases were flukes," said the FDA's Carol Herman, "until we started digging."

The FDA now considers lap and wheelchair belts, fabric body holders and restraint vests to be prescription devices. Manufacturers are subject to FDA inspections to ensure quality control.

Such steps, advocates say, have both reduced and improved the use of restraints. In the mental health field, strong and independent government oversight can weed out bad practices and bad facilities as well, they say.

"We can't do it alone," said Curtis L. Decker of the National Association of Protection and Advocacy Systems. "The only way to truly protect patients is through a large, comprehensive monitoring program."

That means a system where government regulators, not the industry, are charged with oversight, he said. An internal patient grievance system would be bolstered by a well-funded network of independent advocates trained in death investigations.

More than money, though, many analysts say a culture in which restraints are used too soon, too frequently and for the wrong reasons must be changed.

"The single biggest prevention method is the avoidance of restraints to begin with," Sundram said. "It is often the training and opinions of staff that dictate restraints, rather than patient behavior."

In Tennessee, "the changes were top-down, bottom-up and a hard sell everywhere," Sullivan said. Before taking the top Tennessee job, Sullivan spent 27 years as an official in Connecticut's Department of Mental Retardation.

Reducing restraint use was just one of many changes forced on Tennessee by two lawsuits filed by the U.S. Department of Justice and by patient advocates. "It was a system that was disintegrating," said Ruthie Beckwith of People First of Tennessee, a patient advocacy organization that sued the state.

The state responded with new leadership, more money and staff and an intensive training regimen emphasizing calming words instead of brute force.

The total cost for the Jordan Center: $12,665 for training in restraint use and alternative methods; $255,372 annually in additional staffing to address not only restraint issues but massive deficiencies in overall patient care.

The changes in technique weren't easy on staff. About a half-dozen aides quit. Others groused. But most stayed and changed.

"It was a rough couple of months," said Robert Zavala, an aide at Jordan. "At first, they just told us we couldn't put our hands on them. Everyone was like, 'Oh, so all I can do now is run away?' "

Bernard Simons, the Clover Bottom superintendent who oversaw the transition, remembers a defining moment. He received a frantic call from staffers at Jordan saying a patient was smashing furniture and asking whether they could restrain him.

"I said, 'Let him break it,' " Simons said. "So you're going to risk hurting yourself or the patient for a $100 coffee table? The state will buy a new one."

The changes are both profound and surprising to staff and patients who remember the old ways.

"Before, we weren't earning their respect, it was just fear," said Overton, the burly aide who still wears a belt that says "Boss."

"Now, I'm more of a counselor or big brother than an enforcer," Overton said. Like a Cold War relic, he now uses skills other than just his brawn, such as his woodworking knowledge, which he passes on to patients in a new class he teaches.

"I used to get shuffled a whole lot of times when I would go off and hit someone," said David Holland, 24, who has been at the Jordan Center for 2 1/2 years. "Now, they give us a lot more time to chill out, calm down. It's getting better each day."

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