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Opinion & Essays - Sep, 1999 Issue #61

Restraints in Residential Treatment Programs
By E. Clarke Ross, D.P.A., Deputy Ex. Dir. for Public Policy
NAMI – National Alliance for the Mentally Ill
Arlington, Virginia

[Use of restraints in mental health programs has always been controversial, balancing the values of allowing patients freedom of movement against the need at times to protect some patients from themselves. The issue has heated up in the last few months since the Hartford Connecticut Courant newspaper published an extensive list of deaths over the past several years, stemming from restraints of patients (Woodbury Reports #55, Dec. 98/Jan.99, Seen N’ Heard: http://courant.com/news/special/restraint). Mr. Clarke, with the National Alliance for the Mentally Ill (NAMI) was kind enough to prepare an article for this newsletter based on NAMI’s knowledge of this controversy and their official proposals. –Lon]

Placing your child out-of-home, for whatever reason, is a difficult and frequently painful experience. Families whose child is disabled with mental illness hope and pray for what author William Styron called his “Safe Haven.” Shelter, security, treatment, learning, growth and development, and even recovery are hoped for in such placements. A growing number of families are placing their loved ones in facilities labeled by private health insurance and Medicaid as residential treatment centers (RTCs).

Unfortunately, experiences documented by the Hartford Courant in their October 1998 series, by NAMI’s 1999 “Cries of Anguish” compilation, and by television shows such as the 1999 60 Minutes II – Unsafe Havens – document the frequent and life threatening use of restraint in these RTCs. NAMI’s “Cries of Anguish” documented 39 incidents of inappropriate use of restraint in 19 states, including five deaths. Four of the five deaths over a five month period from NAMI’s “Cries of Anguish” were children and adolescents, three in RTCs. The youngest of these deaths was a nine year old, 53 pound boy, crushed to death in a disciplinary physical restraint in a RTC advertising itself as a medication- free specialty facility for children and adolescents with psychiatric illnesses.

The decision to place a child out-of-home is already difficult; now it may be compounded by subsequent death, physical injury, or lasting psychological harm. Why do these deaths and injuries occur? They occur because there is no evidence-based peer researched foundation for the use of restraint. Inadequately trained and understaffed facility aides will often resort to the use of restraints because they are common and there are no national standards governing their use. Residential treatment centers in particular, have no national uniform standards regarding clinical care, avoidance of abuse and neglect, and the use of restraint and seclusion.

Professionals disagree about the use of seclusion and time-out. There is also a fine-line between appropriate use of medications in the treatment of childhood mental illness and what some advocates call “chemical restraint,” the use of medication for discipline and staff convenience. Meanwhile, there is no database of evidence supporting the use of physical and mechanical restraints, nor for the use of restraint and seclusion in combination.

Given the national attention given to deaths and injuries resulting from the use of restraint, members of the United States Congress have introduced legislation to standardize the use of restraint and seclusion in any facility receiving Medicare or Medicaid financing for treatment of a psychiatric illness. These legislative proposals are S. 736 by Senator Joseph Lieberman (CT), S. 750 by Senator Christopher Dodd (CT), and H.R. 1313, by Representatives Diana DeGette (CO), Pete Stark (CA), and Rosa DeLauro (CT). These legislative proposals would: (1) specify that restraints may only be used for emergency safety situations as ordered by a physician and (2) mandate the reporting of all deaths and serious injuries to a third party investigative agency.

As you consider placing your child in a residential treatment program for the treatment of their mental illness, ask the facility a variety of questions: (1) Are physical and mechanical restraints used? (2) Who authorizes the initial use of the restraint? (3) Who can terminate a restraint? (4) Who authorizes the continuation of the restraint? (5) For what purposes are restraints used? (5) What is the evidence-based peer-researched literature affirming the use of restraints? (6) Are people who apply restraints trained to attempt alternative methods prior to using restraints and are they trained in appropriately applying the restraints? (7) How many children during the past month, and the past year, have been placed in restraints? (8) Were there any deaths and serious physical injuries associated with restraints during the past month, past year? (9) Are parents notified when their child is placed in restraints? (10) Are the children de- briefed after the restraint episode has occurred?

By asking these questions and by supporting a national legislative standard, you can be assured that the residential treatment center is a safe haven and not an environment where the safety and security of the child is questionable.

Copyright © 1999, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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