Deaths From Restraints in Psychiatric Facilities: Hearing

S. HRG.
10693
DEATHS FROM RESTRAINTS IN

PSYCHIATRIC FACILITIES
HEARING
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
UNITED STATES SENATE
ONE HUNDRED SIXTH CONGRESS
FIRST SESSION
SPECIAL HEARING
Printed for the use of the Committee on Appropriations
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COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington FRANK R. LAUTENBERG, New Jersey
MITCH MCCONNELL, Kentucky TOM HARKIN, Iowa
CONRAD BURNS, Montana BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama HARRY REID, Nevada
JUDD GREGG, New Hampshire HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas RICHARD J. DURBIN, Illinois
JON KYL, Arizona
STEVEN J. CORTESE, Staff Director
LISA SUTHERLAND, Deputy Staff Director
JAMES H. ENGLISH, Minority Staff Director
SUBCOMMITTEE ON DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND

EDUCATION, AND RELATED AGENCIES
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
SLADE GORTON, Washington ERNEST F. HOLLINGS, South Carolina
JUDD GREGG, New Hampshire DANIEL K. INOUYE, Hawaii
LARRY CRAIG, Idaho HARRY REID, Nevada
KAY BAILEY HUTCHISON, Texas HERB KOHL, Wisconsin
TED STEVENS, Alaska PATTY MURRAY, Washington
JON KYL, Arizona DIANNE FEINSTEIN, California
ROBERT C. BYRD, West Virginia
(ex officio)
Professional Staff
BETTILOU TAYLOR
MARY DIETRICH
JIM SOURWINE
AURA DUNN
ELLEN MURRAY (Minority)
Administrative Support
KEVIN JOHNSON
CAROLE GEAGLEY (Minority)
(II)
CONTENTS
Page
Statement of Hon. Joseph I. Lieberman, U.S. Senator from Connecticut .......... 1
Statement of Hon. Christopehr J. Dodd, U.S. Senator from Connecticut ........... 1
Opening statement of Senator Specter .................................................................. 1
Prepared Statement of Senator Joseph I. Lieberman .......................................... 4
Prepared Statement of Senator Christopehr J. Dodd ........................................... 8
Remarks of Senator Tom Harkin ........................................................................... 9
Statement of Catherine Jean Allen, Ph.D., Greensboro, NC ............................... 11
Prepared statement .......................................................................................... 13
Statement of Wanda Mohr, Ph.D., assistant professor of nursing, University
of Pennsylvania .................................................................................................... 15
Statement of Joseph Rogers, executive director, Mental Health Association
of Southeastern Pennsylvania, National Mental Health Association .............. 20
Prepared Statement ......................................................................................... 22
Statement of Dennis OLeary, M.D., president, Joint Commission on Accredi-
tation of Health Care Organizations .................................................................. 26
Statement of Thomas Harmon, executive secretary, Medical Review Board,
New York State Commission on Quality Care .................................................. 31
MATERIAL SUBMITTED SUBSEQUENT TO CONCLUSION OF HEARING

Prepared statement of the American Psychiatric Association ............................. 41
Prepared joint statement of general principles on seclusion and restraint
by the American Psychiatric Association and the National Association of
Psychiatric Health Systems ................................................................................ 45
(III)
DEATHS FROM RESTRAINTS IN PSYCHIATRIC
FACILITIES
TUESDAY, APRIL 13, 1999
U.S. SENATE,
SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN
SERVICES, AND EDUCATION, AND RELATED AGENCIES,
COMMITTEE ON APPROPRIATIONS,
Washington, DC.
The subcommittee met at 9:30 a.m., in room SD192, Dirksen
Senate Office Building, Hon. Arlen Specter (chairman) presiding.
Present: Senators Specter and Harkin.
CONGRESSIONAL WITNESSES
STATEMENTS OF:
HON. JOSEPH I. LIEBERMAN, U.S. SENATOR FROM CONNECTICUT
HON. CHRISTOPEHR J. DODD, U.S. SENATOR FROM CONNECTICUT
OPENING STATEMENT OF SENATOR SPECTER
Senator SPECTER. We come to order for this hearing of the Ap-

propriations Subcommittee on Labor, Health and Human Services
and Education, and Related Agencies. We will begin now that it is
9:30 a.m., the convening time. After this hearing was scheduled,
the President set a briefing for members of Congress, so we are
going to have to conclude this hearing promptly at 10:30 a.m.
While the openings have never been long at the allocation of time
at 5 minutes, we are going to try to do them in 4. I am sorry about
the time limitations, but I know you will understand that there are
so many issues and Kosovo takes second place to nothing.
This hearing has been scheduled in response to grave concern
about an alarming number of deaths resulting from physical re-
straints in psychiatric facilities. It is impossible to say how many
there are because there is no requirement for reporting of deaths
from physical restraints, in a field which is largely left unregu-
lated.
It is surprising, because patients in nursing homes are protected
by federal legislation from the 1987 Omnibus Budget Reconciliation
Act, but no similar provisions apply to people in psychiatric institu-
tions.
The federal government has a very vital role in this area, consid-
ering that some $14 billion a year is provided by the federal gov-
ernment for funding of psychiatric care. The kinds of restraints
which are used are chemical, physical. While they are obviously
(1)
2
necessary in some cases, there have been reports that they have
been used for convenience, coercion or retaliation.
These issues have come to the public floor as the result of an illu-
minating series in the Hartford Courant. So this hearing is going
to be focusing on just what kind of restraints are used and to what
extent HCFA from the Department of Health and Human Services
ought to be involved.
We are joined by two very distinguished members of the U.S.
Senate, the distinguished senior senator, Senator Dodd, elected in
1980, a colleague of mine from that election. We have worked very
closely on juvenile matters and health matters over the years. We
welcome him here.
Senator DODD. Thank you, sir.
Senator SPECTER. And his distinguished colleague, Senator Jo-
seph Lieberman, elected in 1988, ranking member of the Govern-
mental Affairs Committee.
We welcome you here, gentlemen. As I had said a moment ago,
because of the Presidents briefing, it will require us terminating
at 10:30 a.m. I am going to submit my longer opening statement
for the record. And to the extent we can confine statements to 4
minutes, it would be appreciated. But you men have presided at
enough of these similar hearings to know precisely what is in-
volved.
Senator SPECTER. Senator Dodd, welcome, and the floor is yours.
Senator DODD. Thank you, Mr. Chairman. But I would like to
defer to my colleague, if I may, who is
Senator LIEBERMAN. No. You go ahead.
Senator DODD. Are you sure? Joe has done a tremendous amount
of work on this, and I appreciate yourI try to remind him all the
time I am his senior senator, but he has done so much work on
this, I really wanted to give him a chance to go ahead.
Why do you not do that?
Senator SPECTER. Senator Lieberman, the floor is yours. I note
that notwithstanding seniority and chronology, your bill was intro-
duced slightly ahead.
Senator DODD. I want the record to show that.
Senator LIEBERMAN. No; I am grateful to my colleague. And it is
true, he has reminded me so effectively that he is my senior col-
league, I automatically deferred to him. But I appreciate his gra-
ciousness. I will try to respond by abbreviating my statement and
submitting a larger one for the record.
Senator SPECTER. Thank you very much.
SUMMARY STATEMENT OF SENATOR LIEBERMAN
Senator LIEBERMAN. Mr. Chairman, I want to thank you for hold-

ing this hearing on the deadly use of restraints in mental health
facilities and giving Senator Dodd and me the opportunity to tes-
tify.
As you referenced, last October all of us, and I mention myself
here, read with increasing horror and shame a brilliantly inves-
tigating and written series in the Hartford Courant, describing 142
deaths that were caused by restraint and seclusion in mental
health facilities in our country over the last 10 years.
3
In many ways, it was a trip back into medieval times, to a world

that, except for this journalistic series, would, for me at least, have
been well beyond the limits of my knowledge, a kind of venture
into an existence that otherwise would have been invisible to most
of us. Although the federal government funded much of the care of
these patients, these victims enjoyed almost no federal protections,
certainly not relevant to what was done to them. Even basic infor-
mation about the number and circumstances of their deaths was
difficult for their loved ones to obtain.
So I come to this hearing today with a sense of anger over the
treatment of some of the most vulnerable people in our society and
with a determination to work with you, Mr. Chairman, with Sen-
ator Dodd and others, to prevent future deaths and injuries from
the improper, I may say so, at times barbaric use of restraints.
I also come with a sense of urgency. Just last Friday I learned
of yet another young boy who died in a mental health facility in
Chesterfield, Virginia, after the apparently improper use of re-
straints and seclusion. The facts certainly seem to warrant the con-
clusion that restraints and seclusion are cruelly over used in Amer-
icas mental health institutions today. They are used inhumanly,
and they are too often used with fatal results.
Let me briefly share some of the major conclusions of the Hart-
ford Courant articles. Deaths were reported in 30 states, including,
as you know, Mr. Chairman, Pennsylvania. Thirty-three percent of
the victims were suffocated. More than 26 percent of those killed
were children under 17, a rate that is nearly twice the proportion
of that age category in mental health institutions.
Of course, aggregate statistics do not adequately convey the trag-
edies experienced by the families of these people across this coun-
try. The victims stories will and would better describe the agonies
of their loved ones deaths. Shortly you will hear from Jean Allen,
who will describe the parental nightmare she experienced, the
death by suffocation of her 16-year-old son Tristan Sovern. As a
parent, I extend my sympathy to her and to other parents whose
children have died merciless deaths in restraints. As a senator, I
express my commitment to work with my colleagues to prevent fur-
ther such tragedies.
Mr. Chairman, I applaud your efforts to make sure that the men-
tal health care funded by your committee does not result in injury
or death. You have acted more quickly than any other committee
of Congress to address this national shame.
Now the legislation that Senator Dodd and I have introduced
would extend existing nursing home standards on the use of re-
straints to mental health patients and add a reporting requirement
for injuries and death. Our Connecticut colleague representative,
Rosa Deloro, and others have introduced companion legislation in
the House.
Our bill explicitly forbids the use of restraints unless approved
in writing by a physician, except under emergency circumstances.
In other words, restraints are not to be used for discipline or for
convenience. The same standard in effect in nursing homes since
1987 has reduced the use of restraints by over one-third.
Our bill also requires that facilities report deaths and serious in-
juries to mental health patients under the care of those facilities,
4
so that the cause of death or injury can be analyzed, preventive

steps deployed, and the public alerted. With mandatory require-
ments under a state law in your state, Mr. Chairman, as you know,
Pennsylvania is already producing dramatic reductions in the use
of restraints and seclusions in mental health facilities.
I am encouraged by the response to the legislation. In my printed
statement, I will indicate the number of organizations that I am
proud to say are supporting it. Let me conclude by going back to
the beginning.
PREPARED STATEMENT
I personally, and those of us in Connecticut and around the coun-

try, owe the Hartford Courant a debt for breaking the walls of se-
crecy that concealed 142 deaths caused by the deadly use of re-
straints. Your hearing today is the beginning of action by Congress
that will tear down that wall and erect in its place a better system
of protection for Americas mental health patients.
I thank you. And again, I thank my colleague for his courtesy.
Senator SPECTER. Thank you very much, Senator Lieberman, for
your very insightful statement.
[The statement follows:]
PREPARED STATEMENT OF SENATOR JOSEPH I. LIEBERMAN
Mr. Chairman, Senator Harkin, members of the Committee. Thank you for hold-
ing this hearing on deaths from restraints in mental health facilities.
In October, I read with horror, a powerful, brilliantly investigated and written se-
ries of stories in the Hartford Courant detailing 142 deaths from restraint and se-
clusion in mental health facilities. These deaths stretched over a decade, across the
country, and to patients of all ages.
Although their care was federally funded, few federal protections were available
to the victims and even basic information about the number of victims and the cir-
cumstances of their death was difficult to obtain.
I come to this hearing today, months later but still horrified, still outraged, and
determined to do what I can to prevent deaths and injuries.
I also come with a sense of urgency having read just Friday that another teenage
boy has died in a mental health facility, this time in Chesterfield, Virginia, after
the use of restraints and seclusion.
I strongly urge this Subcommittee to protect mental health patients from the
deadly use of restraints.
Restraints and seclusion are being used too much, they are being used
inhumanely, brutally, and sometimes fatally. This practice is medieval in its appli-
cation.
Here are some of the findings of the Courant articles: deaths reported in 30 states
including both Pennsylvania and Iowa; 33 percent of the victims were suffocated;
and more then 26 percent of those killed were children under 17.
But aggregate statistics can not convey the tragedy of restraints. Let me read
some of the names and circumstances of deaths of victims that were killed during
the months leading up to the death of 12-year old Andrew McClain in Connecticut.
Robert Rollins, age 12, suffocated after a dispute over his missing teddy bear.
Melissa Neyman, 19, suffocated when staffers strapped her to her bed at 10 p.m.
and didnt check on her until the next morning. By then she had been dead 6
hoursentangled in her own restraints.
Edith Campos, 15, suffocated. Edith was looking at a family photograph when a
male aide instructed her to hand over the unauthorized personal item.
Dustin Phelps, 14. Dustin died when the owner of the home wrapped him in a
blanket and a mattress and tied it together with straps, investigators said. He was
left in the mattress for four hours.
You shortly will hear from Jean Allan who can describe the death by suffocation
of her 16-year old son, Tristan Sovern.
I am appalled by these deaths, as I am sure this Subcommittee is.
5
As a parent, I wish to extend my sympathy to Jean Allan and other parents
whose children died in restraints.
As a Senator, I am outraged and want to work with my colleagues to prevent
these deaths. One of the basic purposes of government is to protect those who cant
defend themselves.
Chairman Specter and Ranking Member Harkin, I applaud your efforts to make
sure that the mental health care funded by your Committee is not deadly or inju-
rious. Federal funding sources including Medicare, Medicaid, and SAMHSA com-
prised almost 40 percent of the $36 billion that flowed into mental health organiza-
tions in 1994. You have acted more quickly than any other Committee of Congress
to address this national shame.
I have introduced legislation with Senator Dodd that would to extend existing
nursing home standards on the use of restraints to mental health patients and add
a reporting requirement for deaths and serious injuries to mental health patients.
Reps. Degette, Stark, and DeLauro have introduced restraint legislation in the
House.
Our bill forbids the use of restraints unless approved in writing by a physician,
except under emergency circumstances.
This same standard has reduced the use of restraints in nursing homes by over
a third this decade. Our bill would extend this success to the entire nations mental
health community.
The reporting requirement in our bill mandates that facilities report deaths and
serious injuries to mental health patients under their care so that the cause of the
tragedy can be analyzed, preventative steps developed, and the public alerted. With
mandatory reporting, Pennsylvania is producing dramatic reductions in the use of
restraints and seclusion in their state mental hospitals.
I am encouraged by the response to the legislation.
The bill is supported by the National Alliance for the Mentally Illtwo of whose
Connecticut affiliate presidents, Karen Hutchin of Granby, CT and Jeanne Landry-
Harpin of Woodbridge, CTplayed a critical role in helping the Hartford Courant
investigate and organize its series last year.
It also is supported by the Joint Commission on Accreditation of Healthcare Orga-
nizations, the association which sets standards for the health care industry. They
support the mandatory reporting and disclosure of deaths related to the use of re-
straints.
Other supporters include the National Mental Health Association, the National
Association of Protection and Advocacy Systems, the Bazelon Center for Mental
Health Law.
The wall covering 142 deaths was broken by the Hartford Courant. Your hearing
today is the beginning of action by Congress that will tear the wall down and build
in its place a system of protection for Americas mental health patients.
I applaud your action and thank you for your time.
SUMMARY STATEMENT OF SENATOR DODD
Senator SPECTER. Senator Dodd.

Senator DODD. Thank you very much, Mr. Chairman. And I am
very pleased to be sharing this witness table with my colleague
from Connecticut. We have introduced two bills and are co-spon-
soring each others because they involve different committees of ju-
risdiction, so avoiding the consequential referrals. The bill that Joe
has talked about I think goes to finance, or at least part of it does
anyway, because it touches on HCFA, and the legislation that we
both introduced that goes specifically to the Labor Committee,
where SAMSA legislation has to be reauthorized this year.
And obviously, a critical piece of that obviously comes to you, be-
cause we will be talking about resources that will be needed if
major parts of our legislation are going to be funded. So I am deep-
ly appreciative to you and to Senator Harkin, with whom I have
the pleasure of serving on the Labor Committee.
And as you pointed out, Mr. Chairman, I have had the pleasure
for the past 18 years of working with you on countless issues in-
volving children. And it seems rather natural to be appearing be-
6
fore you today on an issue, as Senator Lieberman has pointed out,

where 26 percent of these deaths that we are talking about oc-
curred to juveniles, a percentage vastly in excess of the percentages
in the population of mental health patients.
I note here, just looking at some of the notes here prepared by
various groups and organizations, this one here, as we talk about
142 deaths that the Hartford Courant included in its series of arti-
cles, it has been pointed out that there have been 5 additional
deaths in the last 5 months. And just noting the ages of 17, 15, 16
and 9, 4 out of the 5, one an adult of 36, just to dramatize the point
that this is particularly an issue that affects all people, but it
seems particularly hard to understand how a 9-year-old could die
as a result of excessive restraint.
It was on March 22, 1998, just about a year ago, Mr. Chairman,
that a 90-pound, 4 foot, 6 inch tall 11-year-old boy in Portland,
Connecticut, had his chest crushed as a result of restraints in a
mental health facility in the State of Connecticut. Andrew McClain
is really what provoked in many ways the series of articles pre-
pared and written by the Hartford Courant.
And I would like to ask, and you may have already done this be-
fore I walked in, but maybe as part of the record those articles be
included, since they were so important in causing Senator
Lieberman and I and you made note yourself and others to really
decide this is an issue we ought to look into. And particular com-
mendation, I think, should go to Eric Weiss, who is the principal
author of these articles, but were supported by Dave Altimari,
Dwight Blint and Kathleen Neegan, who all put those articles to-
gether.
Senator SPECTER. Without objection, they will be made a part of
the record.
Senator DODD. Thank you, Mr. Chairman.
As a result of that, those series of articles, your interest and the
interest of others, we have a wonderful chance in this first session,
I think, of this Congress to be able to do something about this
issue. We have, I said, Tom, before you walked in, the SAMSA leg-
islation up in our committee, the Chairmans interest in this. We
can bring these issues together and the work with HCFA.
Let me just briefly, we do three things in our bill, Mr. Chairman,
as I am sure you are aware. First, we set standards for restraint
and seclusion use, as Senator Lieberman has already pointed out
here. Again, the only reasonno longer can reasons be used of dis-
cipline, punishment or convenience be tolerated in the area of phys-
ical restraints or seclusion.
We also require a physicians written order specifying the length
and circumstances under which restraints may be applied. This
isagain, we are applying the standards that have been used in
nursing homes, I think rather effectively, by modifying the legisla-
tion that would allow for those standards now to be used in mental
health facilities.
Second, Mr. Chairman, we have discoveredand again, both you
and Senator Harkin, I am preaching to the choir on this issue, but
the least trained people in the entire health care fields are people
in mental health. The lowest paid, least well trained are in mental
7
health. It is just an amazing statistic, but it happens to be the

case.
And what we try to do with our legislation is to see if we cannot
help out here, because these are good people in places. They need
to be trained and understand what needs to be done. And we do
not want to be suggesting, I do not want to be, that people who
work in these facilities are criminals in some way. This requires
the kind of training and backing that is necessary.
Only three States, California, Colorado, and Kansas, license
aides in psychiatric facilities. Out of 50 states, only 3 do. And while
individual States or facilities may set their own standards, and we
respect that, there is no uniform minimum training stated for men-
tal health care workers. Our legislation will help ensure that ade-
quate staffing levels and appropriate training for staff facilities will
serve the mentally ill.
Specifically, the legislation requires the Secretary of Health and
Human Services to set regulations requiring mental health pro-
viders to adequately train their staff in the correct application of
restraints and their alternatives to ensure that appropriate staffing
levels are maintained.
A staff person, I might point out, with 23 years of experience,
Mr. Chairman, was quoted in the Hartford Courant series, she
said, Every time weve had a downsize in staff, weve had an in-
crease in restraints and seclusion. So there is a direct correlation.
Third and last, Mr. Chairman, we will ensure that providers who
violate the rights of the mentally ill will be held accountable. And
this underscores Senator Liebermans comments of the abhorrence
with which we read these stories and find out what happens to
these people, particularly again on children.
My bill, this bill rather, will amend the protection in advocacy for
mental ill individuals, so that the state advocacy systems are spe-
cifically granted the authority to investigate and prosecute deaths
and serious injuries resulting from improper restraint and seclu-
sion use. It will also require mental health care providers to notify
their states protection and advocacy organization of all the deaths
that occur in their facility, at their facilities. It is incredible to me
in 1999 that that has not been required, that only three states
have any standards in this area at all.
And last, we grant the Secretary of Health and Human Services
the authority to end any federal funding for mental health care
providers that violate the protections that this bill would establish.
We think that alone may have the greatest impact in getting the
kind of compliance that is necessary.
Again, Mr. Chairman, we thank you immensely for your interest
in this, Senator Harkins interest, confident in this session of Con-
gress we can get some good work down in any area that cries out
for attention.
PREPARED STATEMENT
Senator SPECTER. Thank you very much, Senator Dodd, for that
important statement. And thank the two of you gentlemen for your
leadership. This subcommittee will be picking it up, and we will ob-
viously have the important funding responsibilities on this enor-
mously important matter.
8
Thank you very much.

Senator DODD. Thank you.
Senator LIEBERMAN. Thank you.
PREPARED STATEMENT OF SENATOR CHRISTOPHER J. DODD
I want to begin this morning with a brief story that may illustrate why we are
here. On March 22, 1998, in Portland, Connecticut, 11 year old Andrew McClain
4 feet 6 inches tall and weighing 90 poundswas held down by two staff members
of a psychiatric hospital because of a disagreement over where he would sit for
breakfast. His chest was crushed and he died as a result. The death of Andrew, like
those of more than 140 mental patients around the country cited in a Hartford Cou-
rant series, was tragic and preventable.
That is why we are here todayto help make sure that no family ever has to bury
another Andrew McClain. Thank you Senators Specter and Harkin for convening
this mornings hearing and for examining the national tragedy that these deaths
represent. As Senator Lieberman mentioned, the bills that weve introduced recently
differ in various respects. But, taken together, they share a common core: they cre-
ate tough new limits on the use of potentially lethal restraintsbe they physical
or chemical in nature; they set rules for training mental health workers; and they
increase the likelihood that a wrongful death of a mental health patient will be in-
vestigated and prosecutednot ignored.
The legislation I introduced contains these core provisions. Let me go into them
with a bit more detail.
First, we will set standards for restraint and seclusion use
Physical and chemical restraints may only be used when a patient poses an immi-
nent risk of physical harm to himself or others. We also require a physicians writ-
ten order specifying the length and circumstances under which restraints may be
applied. No longer will the use of restraints for reasons of discipline, punishment,
or convenience be tolerated.
As Senator Lieberman mentioned, we will extend to the mental health population
an existing standard enacted as part of the 1997 Omnibus Budget and Reconcili-
ation Act that has already proven effective in reducing the use of restraints in nurs-
ing homes.
Second, we will ensure adequate staff training and staff levels
Mental health aides are consistently the least-trained and lowest-paid workers in
the health care field. Only three StatesCalifornia, Colorado, and Kansaslicense
aides in psychiatric facilities. While individual States or facilities may set their own
standards, there are no uniform or minimum training standards for mental health
care workers.
My bill will help ensure adequate staffing levels and appropriate training for staff
of facilities that serve the mentally ill. Specifically, my bill requires the Secretary
of Health and Human Services to set regulations requiring mental health providers
to adequately train their staff in the correct application of restraints and their alter-
natives and to ensure that appropriate staffing levels are maintained.
As a staff person with 23 years of experience was quoted in the Courant series,
Every time weve had a downsizing of staff, weve had an increase in restraints and
seclusion. This provision will ensure that restraint use is not as result of staff
shortages or inadequate training.
Third, we will ensure that providers who violate the rights of the mentally ill will
be held accountable
My bill will amend the Protection and Advocacy for Mentally Ill Individuals Act
(PAMII), so that State advocacy systems are specifically granted the authority to in-
vestigate and prosecute deaths and serious injuries resulting from improper re-
straint and seclusion use.
My legislation will also require mental health care providers to notify their States
Protection and Advocacy Organization of all deaths that occur at their facilities.
My bill will also grant the Secretary of Health and Human Services the authority
to end any Federal funding for mental health care providers that violate the protec-
tions the bill establishes.
As the Courants series mentioned, we regulate the size of eggs, how our pets may
be groomed, how manicurists are trained, yet we have not established a standard
of care for some of our most vulnerable citizens. The legislation Senator Lieberman
9
and I have introduced offers a significant step toward protecting those who may not
be able to protect themselves.
It is regrettable that it took the deaths of so many innocent victims to stir Con-
gress to act. I can think of no higher priority for this Congress than the enactment
of this important legislation. Such legislation is an attempt to carve something of
value and meaning out of the tragedy of more than 100 restraint related deaths.
REMARKS OF SENATOR TOM HARKIN
Senator SPECTER. Before calling on the ranking member, may I

ask the next panels to come up?
Senator HARKIN. I just want to thank both Senator Lieberman
and Senator Dodd. And please also take back our gratitude to the
Hartford Courant for doing a great series of articles. This never
would have come to light if they had not done an extensive inves-
tigative reporting on it. They deserve some prize for that. I do not
know what they give out, but they deserve a prize.
Senator DODD. Well, the Hartford Courant won a Pulitzer today
but on another subject matter.
Senator LIEBERMAN. We are going to give them the Harkin prize.
Senator HARKIN. Whatever it is. Something more meaningful
than that.
Senator SPECTER. Now before calling on our distinguished rank-
ing member, let me ask the two panels to come simultaneously, Dr.
Allen, Dr. Mohr, Mr. Rogers, Dr. OLeary, and Mr. Harmon, so we
can expedite the hearing.
Now it is my pleasure to call on the distinguished ranking mem-
ber, Senator Harkin.
Senator HARKIN. Thank you very much, Mr. Chairman. And
thank you for calling this most important hearing.
You know, as often as we are involved in these issues, sometimes
things just sort of slip by. You know, we have so many things on
our plate to pay attention to. And I just must tell you, as the au-
thor of the Americans with Disabilities Act, I take a particular in-
terest in this issue. And I am amazed at how much I am now
learning that I did not know about it before. And that is an indict-
ment of myself for not being more cognizant of this issue. And
again, I am really grateful to the Hartford Courant for the series
that they have done on this.
When I think about this, I think of young Chris Campbell from
the State of Iowa, my home state, 13 years old, weighed 90 pounds.
In the last 24 hours of his life, he was physically restrained 4 times
by staff. During the fourth time, he died.
Again, he is an example of one of the major findings by the Hart-
ford Courant that younger people with mental disabilities are the
group that is most vulnerable to abuse and death caused by the in-
appropriate use of restraints.
I especially want to thank Jean Allen and Joseph Rogers for com-
ing forward today to tell their personal stories. Mrs. Allen, I was
sorry to learn that your adopted son, Tristan, died while being re-
strained by staff. And Mr. Rogers, I know that your past experience
of being placed in restraints will be enlightening to all of us. And
I commend both of you for the courage that you have to come for-
ward.
So again, Mr. Chairman, this is an issue that, again, sitting here,
I do not know exactly what we have to do. But when I found out
10
that only three states have licensing and standard requirements,

something is wrong out there. And I think we are going to have
to take a really serious legislative look at what we need to do in
this area. And I hope through this hearing, Mr. Chairman, that we
will get a better idea of exactly what we ought to be doing legisla-
tively on this thing.
Again, I thank you for bringing us together for this very, very
important issue.
Senator SPECTER. Thank you very much, Senator Harkin.
NONDEPARTMENTAL WITNESSES
STATEMENT OF CATHERINE JEAN ALLEN, Ph.D., GREENSBORO, NC
Senator SPECTER. We now turn to our first witness, Dr. Jean
Allen, who combines a professional standing with this issue. A
Ph.D., in human development, family studies from the University
of North Carolina, Greensboro, and tragically lost her 16-year-old
son, Tristan Sovern, last year when 7 staff members of a private
psychiatric facility restrained him face down, wrapped a bed sheet
around his head, resulting in his death, the official cause ruled suf-
focation, and is a very poignant and striking example of the exces-
sive use of restraints resulting in a death and a great tragedy.
Thank you for joining us, Dr. Allen, and we look forward to your
testimony.
Dr. ALLEN. Thank you, sir.
I speak with you as the mother of a 16-year-old who died need-
lessly. His picture is up here. He is the child on the top row, far
right. A child who should have been finishing his junior year in
high school and looking forward to fulfilling his dream of earning
his diploma as part of the class of 2000.
Our son was hospitalized for a severe depressive episode. On the
morning of his sixth day, my husband and I attended his discharge
planning meeting. At 10:30 p.m. that night, he was dead. In the
days and weeks that followed, the gruesome nightmare of his death
began to unfold. There was a restraint and a seclusion, the second
one in 2 days. Mouth coverings were used both times. In the second
occasion, not one, but two, a large towel plus a bedsheet.
Seven staffers took part in the take-down, meaning that Tristan
was brought down to the floor face down, arms crossed across his
chest, staffers at both of his sides, his feet, his hips and at his
head.
He went through a similar ordeal the night before when, after
becoming agitated, he asked to leave a therapy session. And as he
got up to leave and brushed by a staff person, he was taken down
right outside the door to the therapy room and placed in seclusion
in restraints. It is not clear exactly how long he was in restraints
that night. It may have been longer than 3 hours. We were never
notified of this intervention.
We learned from the staff that Tristans body went limp during
that last restraint. When that happened, no one removed the
mouth coverings nor checked to see if his airway was blocked. He
was carried face down, down a long hallway to a seclusion room,
placed on a bed face down, and his feet were strapped to the foot
of the bed. No one removed the mouth coverings. Still no one as-
sessed his breathing status.
Someone finally thought to call his name. He did not respond.
The mouth coverings were still held in place. The ankle straps
were unbuckled, his body was turned over, and the mouth cov-
(11)
12
erings were finally removed. CPR was unsuccessful, and Tristan

was dead. The official cause of death, asphyxiation.
Hospital reps cited this death as an unfortunate incident. They
stood by their actions, stating the facilities policies and procedures
had been followed. In the multiple investigations that ensued, sev-
eral staffers stated that this type of restraint with mouth coverings
was used approximately 85 to 90 percent of the time, especially
during interventions with adolescents.
When asked to produce the manual that outlined the use of
mouth coverings, the facility could not. Later, facility reps stated
that the unwritten policy had just evolved over the course of the
last five years. Staffers reported that they were never specifically
trained when or how or how not to use mouth coverings, nor were
the risks of using such a procedure covered during staff trainings.
As a part of their damage control, the facility bought several one-
page newspaper advertisements, one of which declared a lack of
national standards. And they capitalized on their JACHO accredi-
tation with commendation.
Something is very wrong with this picture. And children, adoles-
cents and adults are paying with their lives. It is crystal clear that
these tragedies have been allowed to occur in part because there
are no national standards preventing this type of abusive restraint
and seclusion. It is equally clear that the current accreditation and
monitoring process is woefully inadequate. Requirements for staff
training must be established. Accountability must be mandatory.
And enforcement must have teeth.
Facilities must document the specific details of every interven-
tion. Data should be verified by patients, patients families, or
other involved persons. All patient deaths and serious injuries
should be reported and thoroughly investigated. We must have in
place an independent, empowered system of advocacy for these vul-
nerable patients.
Too many emotionally vulnerable and behaviorally disordered
children and adults have already died. But of those healthy, nor-
mally developing children and adolescents who find the cir-
cumstances of their lives too difficult to handle and who begin to
act out, who go into depressions, and whose families seek out pro-
fessional help? What of those who go through this type of therapy
and live through it?
As a last effort, when all other alternatives have failed, proper,
controlled restraint in certain emergency situations may protect an
individual, but being manhandled and treated with disrespect and
inhumanity leaves individuals scarred.
Internalized feelings of anger, rage, abandonment and worthless-
ness are added to their already compromised coping mechanisms,
making them even more vulnerable and emotionally broken. We
must seriously examine the benefits of routine physical interven-
tion against the high cost that patients are paying.
PREPARED STATEMENT
Today I urge the members of the 106th Congress to stand up and

let your voices be heard for the rights of those who have no voice.
Stand up and speak out for the children of the United States and
their families. The Patient Freedom from Restraint Bills are a first
13
step to making the United States a leader in the human rights

mission. How can we demand adherence to human rights standards
of other countries, if we do not take a stand for human rights here
in America? Our children are depending on us.
Thank you.
Senator SPECTER. Thank you. Thank you very much, Dr. Allen,
for sharing with us this tragedy and for your very thoughtful rec-
ommendations.
PREPARED STATEMENT OF CATHERINE JEAN ALLEN
As I appear before you today, I speak with you first as a mother of a child who
died needlessly. A child who should have been finishing his junior year at a local
high school now and looking forward to fulfilling his dream of earning his diploma
as a part of the class of 2000. I also speak with you from a professional stance as
I hold a Ph.D., in Child Development and Family Studies.
On the morning of March 4, 1998, my husband and I attended a discharge plan-
ning meeting at a private psychiatric facility where our son, Tristan, had been for
the previous 6 days. He was hospitalized for a severe depressive episode and he,
his therapist, and we felt he needed constant, close supervision while his medica-
tions could be assessed and changed if needed. At 10:30 that night, Tristan was
dead.
Within 24 hours the coroner reported to us that there was no physiological reason
for our sons death. Our initial thoughts that perhaps he had had some
unexplainable heart attack or brain aneurism were erased. Within the days and
weeks that followed the gruesome nightmare of the circumstances of our sons death
began to unfold.
First, there had been a restraint and a seclusion, the second one in two days.
Mouth coverings had been used both times to prevent biting. On the second occa-
sionnot one, but two: a large towel, plus a bed sheet. On the evening Tristan died,
seven staffers had taken part in the take-down, meaning that Tristan had been
brought down to the floor face down, with arms crossed across his chest; staffers
at both of his sides, his feet, his hips, and at his head.
None of us can really know how frightened and panicked he must have been, be-
cause he had been through a similar ordeal the night before. After becoming agi-
tated, he had asked to leave a therapy session, and as he got up to leave and
brushed by a staff person, he was taken down outside the door to the therapy room
and placed in seclusion in restraints. It is not clear exactly how long he was kept
in restraints that previous night. Nursing notes were vague indicating that he was
restrained and put in seclusion during evening group therapy which usually oc-
curred around 7:30 PM. The 11:00 PM nursing note indicated that he was no longer
pulling at the restraints around his wrists. This was Tristans therapy because he
asked to leave a session. We were never notified of this intervention. I ask you to
consider what it accomplished, other than instilling fear, anger, distrust, and rage?
We learned from the staff that Tristan went limp during the restraint which took
place in his hospital room on the evening of March 4. When that happened, no one
removed the mouth coverings, nor checked to see if his airway was blocked.
He was carried face-down, down a long hallway to a seclusion room, placed on a
bed face-down, and had his feet strapped to the foot of the bed. No one removed
the mouth coverings; still no one assessed his breathing status.
Someone finally thought to call his name; he did not respond. The mouth cov-
erings were still held in place.
The ankle straps were unbuckled, his body was turned over, and the mouth cov-
erings were finally removed. CPR was unsuccessful. Tristan was dead.
Official cause of deathasphyxiation.
The reason for the episode: another adolescent on the unit reported to a staff
member that Tristan had something with which he was going to hurt himself. The
small end of what appeared to be a key chain was found on the top of his dresser
later. It was not in his possession or even near him at the time of the takedown.
Hospital representatives cited Tristans death as an unfortunate incident. They
stood by their actions stating that the facilitys policies and procedures had been fol-
lowed. In the investigations that ensued by the state of North Carolina Facility
Services Division, the Joint Commission on Accreditation of Healthcare Organiza-
tions, the Department of Health and Human Services Health Care Financing Ad-
ministration, and the police, some staffers stated that this type of restraint with
14
mouth coverings was used approximately 8590 percent of the time, especially with
adolescents who were being placed in therapeutic holds and/or transported to the
seclusion/restraint room.
When asked to produce the portion of the Policies and Procedures Manual, that
outlined the use of mouth coverings during holds and restraints the facility could
not. Later facility spokespersons stated that the procedure had just evolved over
the course of the last 5 years. As a part of their damage control, the facility bought
several one-page advertisements in the local newspaper, one of which declared that
there are no national standards . . . The advertisement also touted that the facil-
ity was accredited with commendationthe highest award possiblevirtually the
entire decade. It further stated that on their last JACHO evaluation, the hospital
had received a 96 out of a possible 100 points. How could this be?
A procedure for using a mouth covering during holds and restraints to alter a pa-
tients behavior did not exist in a written policy manual. Staffers reported that they
were never specifically trained when or how to use or not to use mouth coverings.
This fact was corroborated by the Director of Nurses who also stated that the risks
of using such a procedure were not covered during staff training. CPR certifications
were out of date. According to news reports, one staffer who was a part of the re-
straint team, had twice been convicted of assault charges.
Something is very wrong with this picture; and children, adolescents, and adults
are paying with their lives. It is crystal clear that these tragedies have been allowed
to occur simply because there are no national standards preventing this type of abu-
sive restraint and seclusion practice. It is equally clear that the current accredita-
tion and monitoring process is woefully inadequate. Requirements for staff training
must be established, accountability must be mandatory, and enforcement must have
teeth! We must have in place an independent, empowered system of advocacy for
these vulnerable patients.
This system must be federally mandated to receive reports of deaths and injuries
occurring in all facilities so that appropriate investigations and corrective action can
be instituted. There also must be adequate funds devoted to this effort to ensure
that we eliminate these practices. The current nationwide protection and advocacy
system is the appropriate vehicle for this task.
I believe that restraints should only be used as a last resortonly to insure the
immediate safety of the patient or others. Restraints should be used only under a
physicians written order, and in the least restrictive manner possible. Facilities
must document the specific details of every intervention, but also be required to pro-
vide evidence of treatment planning to reduce the need for the use of restraint and
seclusion in the future. These data should be verified by patients, patients families,
or other involved persons. This information should be made available to the protec-
tion and advocacy agency in each state, so that the agency can investigate and cor-
rect systemic abuses. Also, stricter, universal guidelines for the training of staff
must be established.
Finally, accountability must be mandatory. Evaluators must take an active role
in the assessment process which leads to accreditation of facilities that care for peo-
ple with mental illness, emotional and behavioral disorders, chemical dependencies,
and/or developmental disabilities. Evaluations must be rigorous, frequent, thorough,
and unannounced.
Patients and their families should not have to be fearful of neglect and abuse in
the name of therapeutic intervention. Inhumane treatment and disrespect for pa-
tients as human beings can no longer be allowed to be masked under the guise of
a facilitys offer of compassionate, quality, state of the art care.
Too many emotionally vulnerable and behaviorally disordered children and adults
have already died. But what of those healthy, normally developing children and ado-
lescents who find the circumstances of their lives too difficult to handle and who
begin to act out, who go into depressions, who struggle with chemical dependencies
and whose families seek out professional help at some public or private facility, clin-
ic, hospital, or treatment center?
We have begun to identify those who have not survived restraint and seclusion:
Tristan Sovern, age 16; Andrew McClain, 11; Mark Draheim, 14; Edith Campos, 15;
and Timithy Thomas, 9; and all the others identified by the staff of the Hartford
Courant in their investigative probe of last October. But what of those who go
through this type of therapy and live through it? As a last effort, proper, con-
trolled restraint in certain circumstances may protect individuals, but being man-
handled and treated with disrespect and inhumanity will leave these people scarred.
Internalized feelings of anger, rage, abandonment, and worthlessness are added to
their already compromised mechanisms making them even more vulnerable and
emotionally broken. We must seriously examine the benefits of this type of routine
physical intervention against the high costs that patients are paying.
15
A young girl wrote to me after Tristans death. She had been hospitalized at the
same facility as my son. She was 15, an A/B student, an athlete, who found herself,
even with the support of her family, having severe difficulties navigating the road
of adolescence. She was involuntarily hospitalized after going in for a therapy ses-
sion. She was placed in the seclusion room and spent the night huddled on the floor
in the dark wondering if her parents still loved her and if they would ever come
to get her out of this place.
She told me that I must never give up on speaking out for the rights of children
like Tristan, and like herself, for all the children. She wrote that I was the only
voice some of them had, perhaps their only hope.
Today I urge all of the members of the 106th Congress to stand up and let their
voices be heard for the rights of those who have no voice. Stand up and speak out
for the children of the United States and their families. The Patient Freedom From
Restraint Bills are a first step to making the United States a leader in the human
rights mission. How we can demand adherence to human rights standards of other
countries if we do not take a stand for human rights here in America? Our children
are depending on us.
STATEMENT OF WANDA MOHR, Ph.D., ASSISTANT PROFESSOR OF
NURSING, UNIVERSITY OF PENNSYLVANIA
Senator SPECTER. We now turn to Dr. Wanda Mohr, professor
and course director of psychiatric mental health nursing at the
University of Pennsylvania School of Nursing. Dr. Mohr is national
co-chairperson for research and education for the Association of
Child and Adolescent Psychiatric Nursing.
Welcome, Dr. Mohr.
Dr. MOHR. Thank you.
Senator SPECTER. Thank you for joining us, and the floor is
yours.
Dr. MOHR. Thank you.
As a nurse, I am here to tell you that restraints and seclusion
are the most draconian methods of patient control. I have seen
them used, and I have broken up situations that could have turned
potentially tragic.
Imagine what it must be like to be 12 years old, alone, frightened
by voices in your head, not understanding what is happening, and
having 6 to 8 big people surround you, yell at you to calm down.
When you try to run away or defend yourself against these mon-
sters gathered around you, they lunge at you and pin you to the
floor. You cannot breathe, and you tell them. But they pay no at-
tention. After all, you are crazy. They dismiss your complaints by
saying that you are being manipulative. And then things begin to
go black.
At worse, you die calling for your mommy and for help that never
comes. At best, they carry your little body to a bare room, strap you
to a bed spread-eagle, pull down your pants, inject you with drugs,
and leave you alone with the horror for hours at a time. This sce-
nario plays itself out repeatedly in psychiatric hospitals across this
country.
I am an active member of the National Alliance for the Mentally
Ill, the nations largest grassroots voice on mental illness. On
March 25, NAMI released a summary of reports of abuse received
since the October Courant series. Over 5 months, five new deaths
have occurred, four were youths under the age of 8. One was a 9-
year-old boy. And those are only the ones that we know about. Five
deaths in 5 months.
As you consider this proposed legislation, please think about how
many more may die unless you act. I am someone who has had a
16
family member with severe and persistent mental illness. I am a

consumer myself, and I have years of clinical and now academic
nursing experience. From all of these perspectives, I feel competent
to talk about some reasons why restraint situations go out of con-
trol and to give my opinion as to what can be done.
No. 1, seclusion and restraints are psychiatric conventions, rath-
er than interventions that are based on foundations of research.
The use of any therapeutic intervention, such as medication or sur-
gery, in health care should be based on solid scientific data. This
does not happen with restraints.
Lack of meaningful oversight. Hospital accreditation and inspec-
tion is little more than a check of appropriate paperwork. I have
been through many such inspections. And frankly, the representa-
tion of reality by an adequately completed form is problematic.
There is absolutely no evidence that what was written actually
happened.
Lack of staff education and training. The level of employee deal-
ing directly with the most vulnerable patients are the ones with
the least amount of education. There is a pervasive attitude in this
field that anyone can take care of psychiatric patients, especially
in the case of children. We have special standards for staff mem-
bers working in critical care or emergency units, but not in psy-
chiatric settings.
As much as critical care units, the acute care units of psychiatric
hospitals are equally complex and require special training and edu-
cation, especially today when the patients that we are seeing are
the sickest of the sick.
I have made a number of recommendations in my written testi-
mony. And in the interest of time, what I would like to do is to ask
you to enter them into the record.
Senator SPECTER. They will be fully made a part of the record,
without objection.
PREPARED STATEMENT
Dr. MOHR. OK. So in the interest of time, I will defer to Mr. Rog-
ers, because my recommendations are all those that are in the leg-
islation. And I thank you very much and offer myself to any ques-
tions that you might have.
Senator SPECTER. Thank you. Thank you very much, Dr. Mohr.
PREPARED STATEMENT OF WANDA K. MOHR
As a nurse I am here today to tell you that restraint and seclusion are the most
draconian methods of patient control in mental health settings. Ive seen them used,
and Ive broken up situations that could have turned into potential tragedies.
Imagine for a moment, if you will, what it must be like to be 12 years old, alone,
frightened by voices in your head, not able to understand what is happening, and
having six to eight big people surround you and yell at you to calm down. When
you try to run away or defend yourself against the monsters gathered around you,
they lunge at you and pin you to the floor.
In the worst-case scenario you cant breathe and you tell them. But they pay no
attentionafter all, youre crazy. They dismiss your complaints by telling each other
that youre being manipulative. And then things begin to go black.
In the worst-case scenario, you die, calling for your mommy and for help that
never comes. In the best-case scenario, they carry your little body to a bare room,
strap you to a bed, spread-eagle, pull down your pants, inject you with drugs, and
17
leave you alone with the horrorfor hours at a time. This scene is replayed over
and over again in psychiatric hospitals across this county.
I am an active member of the National Alliance for the Mentally Ill, the nations
largest, grassroots voice on mental illness. As someone who had a family member
with severe and persistent mental illness, and being a consumer myself as well as
someone who has years of clinical and now academic nursing experience, I feel
uniquely situated to speak to the issue of restraint.
Last year, NAMI members in Connecticut played a critical role in getting the
Hartford Courant to investigate the use of restraint in psychiatric facilitieswhich
led to publication of the series that documented 142 actual deaths around the coun-
try over a decade and that commissioned a Harvard University report that esti-
mated between 50 and 150 deaths annually as a result of restraint.
On March 25th, NAMI released a summary of reports of abuse received since the
Hartford Courant series was published in October. Over 5 months, five new deaths
occurred. Four were youths under the age of 18. One was a 9-year-old boy. And
those are only the ones we know about.
Five deaths in 5 months.
As you consider the issue, please think about how many more may die.
Unless Congress acts.
I am here today to speak to how and why restraint situations go out of control
and to give my opinion about what can be done to alleviate this problem. In the
interest of brevity I have bulleted my list so that it can be easily perused by this
committee, and I will read some of those. I do ask that my entire testimony as sub-
mitted be entered into the congressional record.
SECLUSION AND RESTRAINT ARE PSYCHIATRIC CONVENTIONS RATHER THAN
INTERVENTIONS BASED ON A FOUNDATION OF RESEARCH
Therapeutic interventions should promote, maintain, or restore health or at least

prevent further illness from occurring. The use of any therapeutic intervention in
a clinical setting should be based on solid scientific data. To date we have very scant
research concerning the effectiveness or the effects of restraint use on patients and
no research on the effectiveness of alternate ways of managing aggressive or violent
behavior (Walsh & Randell, 1995). Placing a patient in restraints remains an un-
questioned and accepted ritual of practice despite recognition by the psychiatric
community that it is governed by consensus rather than research (Rubenstein, 1983;
Goren, 1991; Goren & Curtis, 1997).
LACK OF MEANINGFUL OVERSIGHT
Based on my experience as a practitioner, hospital accreditation and inspection

is little more than a check of appropriate paperwork. I have been through many
such inspections and quite frankly the representation of reality by an adequately
completed form is problematic in that there is no evidence that what was written
actually happened.
Visits are announced. Knowing weeks in advance of a JCAHO visit, hospital ad-
ministrators will often assign additional staff and arrange for charting parties in
which paper work is cleaned up and brought into compliance with standards. This
practice was reported and documented repeatedly during the investigation of the
abuses conducted by the state of Texas and former Representative Patricia Schroe-
ders investigation of those abuses (U.S. Government Printing Office, 1992). Reports
from my colleagues who still practice in clinical settings raise serious doubt that
much has changed with respect to this kind of creative record-keeping.
There are no penalties for non-compliance. At worst, even in the event that ac-
creditation is denied, hospitals do not necessarily suffer ill consequences.
Years ago, we in health care relied on paperwork and asking other professionals
about the efficacy of pain control. We finally woke up to the fact that the patient
is the one who should be asked. While it seems commonsensical to ask the patients
and familiesthe experts in their own experiencesfor their opinions, inspectors do
not independently meet with patients and families to ask about their hospital expe-
rience. The mentally ill still have no credibility. This puts the onus of proof on
the very people who are in a position to alter reality.
NO PROCEDURAL CONSISTENCY
Procedures, standards and regulatory statements on restraint use vary from docu-
ment to document and from institution to institution. Definitions of assault and vio-
lence are loose and articulated in the vaguest of terms and subject to interpretation
(Rice, Harris, Varney, & Quinsey, 1989; National Research Council, 1993).
18
Standards and regulatory documents are based on a number of unspoken assump-
tions that are not true, and I could be here for many hours outlining and debunking
them. But I will focus on a single examplethe assumption that staff members are
adequately trained and educated in the care of vulnerable individuals and that they
can de-escalate potentially explosive situations. In fact, research conducted by
nurses reveals that nurses aides are not cognizant of available alternative tech-
niques to restraint (Neary, Kanski, Janelli, Scherer, & North, 1991). Over 70 per-
cent of these same aides had attended an inservice on the subject one year prior
to this study.
Moreover, so far as I know, procedures for seclusion and restraint are developed
for the most part without consumer input. Their development is driven by external
experts rather than the real expertsthe patients.
Standards and regulatory guidelines are written by persons who are not involved
in the decision to employ the restraints. Psychiatrists issue guidelines and write or-
ders for the use of seclusion and restraint in the abstract. In general they are rarely
involved in observing the incidents that lead up to the necessity for such interven-
tion. They have little day-to-day experience with the cycle leading to the interven-
tion and therefore are not in a position to monitor, nor help to prevent and reduce
their use. Therefore, they dont really see this issue as the problem that it isit
simply is not part of their reality.
LACK OF STAFF EDUCATION AND TRAINING
The employees dealing directly with the most vulnerable patients are the ones
with the least education. This has been the case throughout history, and there is
ample documentary evidence that speaks to this problem (Perrow, 1965; Goffman,
1961; Morrison, 1990).
There are fuzzy requirements for education and training, which seem to be mostly
voluntary. One of the first things to be jettisoned when money gets tight are staff-
development activities (Braxton, 1995). Because training and on-going education are
not universally required, they are considered a luxury more than a necessity.
There is a pervasive attitude that anyone can take care of psychiatric patients,
especially in the case of children. We have special standards for nursing staff who
work in critical care or emergency areas, but no such standards in psychiatric set-
tings. As much as critical care units, the acute care unit of a psychiatric hospital
is a complex milieu with a very difficult population whose brains can feel as though
they are on fire. This is a situation requiring special training and education, espe-
cially today when the patients that we are seeing are the sickest of the sick.
There is a lack of developmentally appropriate programming for patients. This
was another problem that was explored in the National Medical Enterprises inves-
tigation of the early 1990s. Here I would have to reference my own work because
almost nothing has been written or researched about this topic by any one else.
Children of varying ages are mixed with everyone else receiving the same interven-
tions for the same periods of time. Four-year-olds do not have the same capacity
for attention as 14-year-olds, yet they go to 50-minute groups. When they act in a
developmentally appropriate way, by whining or acting up, they are punished and
a cycle of aggression is set up (Goren, Singh, & Best, 1993).
There are too few nurses with too little education. Nurses are costly; thus the ac-
tual number of registered nurses is cut to the bare minimum in the interest of prof-
its. Moreover, the education of nurses is in and of itself a problem. The majority
of nurses (64 percent) do not have even a baccalaureate degree (U.S. Dept. of Health
& Human Services, 1996). Thus, a two-year, associate-degreed registered nurse may
have 7 to 10 days of exposure to psychiatric content. A four-year baccalaureate-
degreed nurse has considerably more, but even he/she is a generalist. I teach an ex-
tremely bright cohort of young people in a baccalaureate program, and believe that
I do so quite competently. Yet I do not believe that the time spent with me qualifies
them to work with such a complex population.
Staff turnover has been repeatedly correlated in the literature with incidents of
violence (Rice, Harris, Varney, Quinsey, 1989). Staff turnover results from poor pay,
poor working conditions, and high levels of stress and frustration due to both a very
challenging population and the lack of skills needed to work with that population
(Braxton, 1995).
A PSYCHIATRIC CULTURE THAT IS IN SERIOUS NEED OF SELF-REFLECTION AND REFORM
Despite much progress in psychiatry and an insistence that psychiatric illness is

brain illness, many psychiatric professionals still want to play under a different set
of rules than their colleagues in other specialties. A situation in which a restraint
takes place is an acute psychiatric emergency that is analogous to any other emer-
19
gency in medicine, and it should be handled by medical personnel as such. A cardi-
ologist would not dream of relegating the assessment of his/her patient to a staff
member after such an event. They would grumble and roll themselves out of bed
to do what they are responsible for doingassess the patient. Yet during this debate
psychiatrists have resisted our suggestions that they subscribe to the same stand-
ards of practice.
Resistance to advocacy groups is common. My experience has been that with
many nurses and psychiatrists there is a general attitude that advocacy groups are
a nuisance and that they make life more difficult for both groups.
Resistance to shared decision-making and a participative model of care is also
common. Nurses and MDs resist consumer input and the input of their families,
even though the families are the repositories of the best information about interven-
tions that may help in treatment. They are reluctant to give up any power to fami-
lies and patients as the ontological arbiters of what is normal. Patients (and their
families) experiences are discounted and considered lacking in credibility. Histori-
cally we have learned little from Rosenhans (1973) work in which he observed that
psychiatric staff members keep to themselves, almost as if the disorder that afflicts
their charges is somehow catching. (p. 254)
Ive made a number of recommendations in my written testimony, but Id like to
highlight just a few today.
Identify, evaluate, and implement promising practices while we conduct clinical
research studies into theory and intervention.
Back research agendas on this issue. Funds to specifically study restraint use,
misuse and best practices must be allocated to agencies such as NIMH (Na-
tional Institute of Mental Health), NIJ (National Institute of Justice), and
NINR (National Institute for Nursing Research).
Insist on greater physician accountability and involvement.
Mandate unscheduled oversight by independent agencies/persons that goes be-
yond exercises in paperwork that is not announced ahead of time.
Require systematic reporting of restraint/seclusion incidents to an independent
agency.
Mandate reporting of sentinel events such as injury and death.
Develop consistent standards for restraint use that are patient- and not staff/
physician-focused, and include consumers in the development of these stand-
ards. Base such standards on the concept that restraints may only be used for
emergency safety situations.
Mandate staff orientation and ongoing education and training that is fully docu-
mented. The literature provides considerable support for the idea that signifi-
cant reductions in institutional violence could be achieved by a staff training
program aimed at teaching non-restrictive and non-authoritarian ways of inter-
acting with residents.
Increase standards for those who can be hired to work with psychiatric patients.
For example, nurses should be certified and have advanced training, and aides
or mental health technicians should have a high school education and special
training and education in the care of psychiatric populations.
Insist that patients and their families are given free access to members of advo-
cacy groups and that the telephone numbers of advocacy groups be prominently
displayed in the living areas of each facility and also given individually to each
patient upon admission.
Provide protection from retaliation to staff members for their advocacy efforts
on behalf of patients.
REFERENCES
Braxton, E.T. (1995). Angry children, frightened staff: Implications from training
and staff development. In D. Piazza (Ed.). When love is not enough: The manage-
ment of covert dynamics in organizations that treat children and adolescents (pp.
1328). New York, N.Y.: The Hawthorne Press.
Goffman, E. (1961). Asylums: Essays on the social situation of mental patients
and other inmates. Garden City, N.Y.: Doubleday Anchor Books.
Goren, S. (1991). What are the considerations for the use of seclusion and re-
straints with children and adolescents. Journal of Psychosocial Nursing and Mental
Health Services, 29(2), 3233.
Goren, S., Singh, N.N., & Best, A.M. (1993). The aggression-coercion cycle: Use
of seclusion and restraint in a child psychiatric hospital. Journal of Child and Fam-
ily Studies, 2(1), 6173.
20
Goren, S. & Curtis, W.J. (1996). Staff members beliefs about seclusion and re-
straint in child psychiatric hospitals. Journal of Child and Adolescent Psychiatric
Nursing, 9(4), 711.
Morrison, E.F. (1990). The tradition of toughness: A study of nonprofessional
nursing care in psychiatric settings. Image: Journal of Nursing Scholarship, 22(1)
3238.
National Research Council (1993). Understanding and preventing violence. Wash-
ington, D.C.: Author.
Neary, M.A., Kanski, G.W., Janelli, L.M., Scherer, Y.K., North, N.E. (1991). Re-
straints as nurses aides see them. Geriatric Nursing, July/August, 191192.
Perrow, C. (1965). Hospitals: Technology, structure, and goals. In J.G. Marsh
(Ed.), Handbook of organizations (pp.4760). Chicago, IL: Rand-McNally.
Rice, M.E., Harris, G.T., Varney, G.W., Quinsey, V. (1989). Violence in institu-
tions: Understanding, prevention and control. London, U.K.: Hans Huber Pub-
lishing.
Rosenhan, D. (1973). On being sane in insane places. Science, 179, 250258.
Rubenstein, H. (1983). Standards of medical care based on consensus rather than
evidence: The case of routine bedrale use for the elderly. Law Medicine and Health
Care, 11, 271276.
U.S. Government Printing Office (1992). Profits of misery: How inpatient psy-
chiatric treatment bilks the system and betrays our trust. Washington, D.C.
U.S. Dept. of Health & Human Services. (1996). National advisory council on
nurse education and practice: Report to the Secretary of the Dept. of Health and
Human Services on the basic registered nurse work force. Washington, D.C.
Welsh, E. & Randell, B. (1995). Seclusion and restraint: What we need to know.
Journal of Child and Adolescent Psychiatric Nursing, 8 (1), 2840.
STATEMENT OF JOSEPH ROGERS, EXECUTIVE DIRECTOR, MENTAL
HEALTH ASSOCIATION OF SOUTHEASTERN PENNSYLVANIA, NA-
TIONAL MENTAL HEALTH ASSOCIATION
Senator SPECTER. Thank you for observing the time limit.
We now turn to Mr. Joseph Rogers, executive director of the
Mental Health Association of Southeastern Pennsylvania and of
the National Mental Health Consumer Self-Help Clearing House.
Mr. Rogers brings both professional and personal insights into this
issue, having first-hand experience with restraints during his own
hospitalization for mental illness.
We appreciate your sharing with us your own private experi-
ences, Mr. Rogers. Thank you for joining us, and the floor is yours.
Mr. ROGERS. Thank you, Senator Specter and Senator Harkin.
On behalf of the Mental Health Association, the National Mental
Health Association, I really want to congratulate you on having
this hearing.
I, too, have extensive remarks that I hope can be entered in the
record.
Senator SPECTER. They will be made a part of the record in full.
Mr. ROGERS. But briefly, as an advocate, as well as someone who
has survived being put in seclusion in restraints, I am deeply con-
cerned about this deplorable practice. My knowledge of the subject
was gained first hand. One of my worst experiences was in a pri-
vate hospital in Florida. I had been brought into the emergency
room from a halfway house on a Friday evening. Although I was
fairly subdued, I was taken to a room with thick, opaque glass
doors and strapped to a platform in five-point restraints.
These are the kinds of restraints that they use in restraining
someone. You get two across the arms around the restraints on the
platform, two across on the legs and
Senator SPECTER. That one is not quite big enough for you,
though, is it?
Mr. ROGERS. They get them bigger. They have them big.
21
There were two each on my wrists and ankles and around and
across my chest. No sound penetrated the room, which contained
nothing but the platform to which I was strapped. Over the next
212 days, I was psychotic and hallucinating and in and out of con-
sciousness. I was left alone to lie in my urine and excrement until
someone came to clean me up once.
When the regular staff replaced the weekend staff on Monday,
they found me filthy and dehydrated. They were shocked and kept
saying that I must have done something to warrant such treat-
ment. But I did not know what I had done.
This may sound extreme, but I have heard many similar stories.
What can be done to stop the abuses we see every day in the use
of restraints? One, we must move away from institutions toward
community-based treatment. We must safeguard the rights of peo-
ple in institutions. The effort to protect peoples rights is central to
Pennsylvanias move toward the elimination of seclusion and re-
straints in its state and private mental hospitals.
I would also like to point out that people with developmental dis-
abilities are also put at risk by the use and abuse of restraints.
I understand that the American Psychiatric Association is claim-
ing that the proposed legislation will have a chilling effect on treat-
ment options and safety issues.
Well, there is nothing more chilling than death. And people are
dying as a result of this so-called treatment, which in reality indi-
cates a treatment failure. We must document that failure so that
we can make needed changes in our system.
Information on the use of restraints is key. One mechanism for
disseminating such information might be under the State Mental
Health Planning Act, which requires that every state submit a
mental health plan to the Federal Substance Abuse and Mental
Health Services Administration. That plan could require informa-
tion on the use of restraints broken down by state and local hos-
pitals, so that a pattern of usage can emerge.
We must involve consumers and family members and the com-
munity in helping develop policies and procedures. We are advo-
cating for a national program of self-advocacy training for con-
sumers of mental health services, because we find that consumers
make the best advocates on such issues as the abuse of restraints.
This program would be implemented through the protection and
advocacy agencies with the assistance of the National Mental
Health Association.
PREPARED STATEMENT
As I mentioned, we must move away from institution toward

community treatment. In the meantime, people who find them-
selves hospitalized must be assured of a safe place. Toward this
end, we would like to see the days when the last available set of
restraints is placed under plexiglass saying obsolete equipment.
We hope proposed legislation takes one step towards that day.
Thank you for your attention.
Senator SPECTER. Thank you very much, Mr. Rogers.
22
PREPARED STATEMENT OF JOSEPH A. ROGERS
Senator Specter, on behalf of the National Mental Health Association as well as
the Mental Health Association of Southeastern Pennsylvania, of which I am execu-
tive director, I want to thank you for holding this hearing on seclusion and re-
straints.
Im here today because I have survived the experience of being put in seclusion
and restraints. As an advocate as well as someone who may need acute psychiatric
services in the future, I am deeply concerned about this deplorable practice, which
has been responsible for numerous deaths as well as many more instances of trau-
ma in those who have experienced it.
Im here to testify that massive changes in the system are needed in order to pro-
tect the lives of people with mental illness.
First, we must move away from institutions toward community-based treat-
ment. It has been repeatedly demonstrated that people do better in the commu-
nity, and that the behaviors that get them in trouble, and into restraints, are
a product of conditions in the institution. Ive been there, and no one should
have to be subjected to those kinds of conditions, where people are crammed
into a small room to spend their days with little to engage them. This kind of
stress definitely has an impact on behavior. So we need to get people out of the
institutions.
Second, we must safeguard the rights of people in institutions. The effort to pro-
tect peoples rights is central to Pennsylvanias move toward the elimination of
seclusion and restraint in its state hospitals, about which I will provide details
later in my testimony. It is my understanding that the American Psychiatric
Association is opposing the proposed legislation and is claiming that it will have
a chilling effect on treatment options and safety issues. Well, there is noth-
ing more chilling than death, and people are dying as a result of this so-called
treatment, which in reality indicates a treatment failure. And we must docu-
ment that failure so that we can make the needed changes in our system.
Third, we need to involve consumers, family members and the community in
helping develop policies and procedures, and in monitoring this situation. And
we need your help: we need federal legislation that mandates that information
be gathered and disseminated. And we need to make that information public.
Then we must ensure that consumer-run self-help organizations, family organi-
zations, and advocacy organizations such as Mental Health Associations and
Protection and Advocacy agencies get the information they need and have the
necessary access to monitor this very dangerous practice.
That being said, I am testifying in support of the legislation proposed by Senators
Joseph Lieberman and Christopher Dodd and by representatives Pete Stark, Diana
DeGette and Rosa DeLauro. We consider this legislation a good first step in regu-
lating the use of seclusion and restraints.
At the same time, it is important to note that the legislation does not go far
enough. Far enough would mean instituting regulations that would either outlaw
the use of seclusion and restraints, or make it nearly impossible to employ them.
In Pennsylvania, our top mental health official, Charles G. Curie, has made it a
goal to eliminate the use of seclusion and restraints in state mental hospitals. This
goal has already been achieved in one state hospital: for the six months before it
closed, as part of Pennsylvanias progressive shift toward community-based services,
Haverford State Hospital did not employ seclusion and restraints.
My testimony will cover the Pennsylvania model, as well as my own personal ex-
perience with seclusion and restraints. I will also suggest ways that the proposed
legislation could be made more effective.
My knowledge of this subject was gained firsthand; I have been repeatedly hos-
pitalized for mental illness and have experienced seclusion and restraints a number
of times.
One of my worst experiences was in a private hospital in Florida. I had been
brought to the emergency room by ambulance from a halfway house on Friday
evening. Although I was fairly subdued, I was immediately taken to a room with
thick, opaque glass doors and strapped to a sort of platform in five-point restraints:
two each on my wrists and ankles and one across my chest. No sound penetrated
the room and, since it contained nothing but the platform to which I was strapped,
there was a nearly complete sense of sensory deprivation.
Over the next two-and-a-half days I was psychotic and hallucinating, and passed
in and out of consciousness. I remember being given some shots. I dont remember
getting anything to eat or drink, although I suppose I must have. I was left alone
to lie in my own urine and excrement, until someone came to clean me up, once.
Most of the time, I was ignored.
23
When the regular staff replaced the weekend staff on Monday morning, they
found me filthy and dehydrated. They were shocked, and kept asking, What did
you do? You must have done something. I had no answer; I did not know what I
had done.
This may sound extreme, but I have heard many similar stories.
Obviously, no ones definition of best practices would include my experience in
Florida. But, unless restraints are outlawed, there will always be the possibility
that inexperienced staff will over-react and violate procedures.
For example, a couple of years ago, when I was left in restraints overnight at a
respected private psychiatric hospital in Philadelphia, I was told later that this was
against hospital procedures. Unfortunately, because of chronic staff shortages and
other administrative shortfalls, not to mention staff who are punitive or frightened,
it seems to be a given that procedures will be violated on a regular basis. Best
practices may dictate the use of restraints only in extreme cases of risk to the pa-
tient or others; but this is not what happens.
In fact, many consumers of mental health services steer clear of going to emer-
gency rooms to seek psychiatric help because of the risk that, if they seem agitated,
they may wind up in seclusion and restraints.
Unless any policy statement outlaws restraints or at least makes it nearly impos-
sible to employ them, there is going to be abuse. If you have an inexperienced nurse
at midnight who is terrified of the patients, policies tend to go right out the window.
By the same token, if you dont have a room equipped with a table to strap people
onto, thats the best guarantee that people wont be restrained against policy.
Its also vital to make sure that chemical restraints are not substituted for tables
and straps. When I have been heavily medicated to make me calm down, I have
found that the effects can last for weeks.
Educating staff in the use of alternatives to restraints is more important than cre-
ating policy to govern the use of restraints, since policy is so often violated.
For the reasons described above and the ones that follow, I fully support the deci-
sion of Pennsylvanias top mental health official, Charles G. Curie, to establish the
goal of eliminating seclusion and restraints in state hospitals.
First, seclusion and restraint are not treatments; they are treatment failures.
Second, seclusion and restraint are high-risk techniques that may resultand
have resultedin injury or death to the patient, both while the patient is being sub-
dued and afterward. In addition, staff injuries decline in frequency and severity
when the need for physical interventions with patients is eliminated.
Third, a high percentage of state hospital patients are trauma survivors, and se-
clusion and restraint are themselves traumatic, for both patients and staff. Hos-
pitals cannot cause trauma and effectively care for people.
Fourth, the use of seclusion and restraint fosters an atmosphere of staff control
over patients rather than the desired treatment partnership.
In 1995, when Mr. Curie assumed his duties as Deputy Secretary for Mental
Health in Pennsylvania, he found that there was a relatively high usage of seclusion
and restraint in some state hospitals.
With the support of others in the department, he took the first step of redefining
the use of seclusion and restraint as a treatment failure, only to be used as a safety
measure of last resort, when all other types of intervention have failed. This re-
sulted in clinicians using alternative interventions, and led to a significant reduction
in seclusion and restraint in most state hospitals.
The Office of Mental Health thus created an environment in which all staff expect
to see a reduction in the use of seclusion and restraint and the risks associated with
their use.
This shift in attitude has been accompanied by dramatic changes in policy and
procedure, Mr. Curie has reported. For example, the departments Bureau of Hos-
pital Operations has developed a system-wide monitoring tool that measures and
compares the incidence and duration of seclusion and restraint in all hospitals. In-
creased emphasis has also been put on staff training on clinical alternatives to the
use of seclusion and restraint, as well as ongoing reinforcement by management of
reducing usage at each hospital. Consequently, Pennsylvania has continued to see
a substantial reduction in the incidence and duration of use of these techniques.
As Mr. Curie recently said:
Pennsylvanias experience proves that the use of seclusion and restraint can be
eliminated or greatly reduced when there is a treatment environment that focuses
on the strengths of the individuals being served; that protects patients dignity, com-
fort, and privacy; that promotes constructive interaction and partnership between
staff and patients; that eliminates arbitrary ward rules developed for staff conven-
ience; that fosters patients ability to make choices and have a greater under-
24
standing of their own behavior; and that involves management and staff in planning
how to reduce the incidence of seclusion and restraint.
The options available today make the elimination of seclusion and restraint an
extremely realistic goal. One such option is use of a new generation of antipsychotic
medications, which are more effective in reducing the symptoms that lead to aggres-
sive behavior. Clearly, medication should be administered only in the context of a
treatment plan in order to relieve symptoms, and not as a chemical restraint.
Clinicians also have a better understanding of the use of verbal de-escalation
techniques to avert physical confrontation. In addition, providing more hours of ac-
tive treatment and more structure and activity for patients during the day would
leave less time for conflicts to erupt between patients and staff.
The Pennsylvania Office of Mental Health and Substance Abuse Services has in-
stituted a standardized, universal risk assessment procedure to help identify people
who may exhibit behaviors that could put them at risk of seclusion and restraints,
and to target those risks through treatment planning. The objective is to help people
learn to manage their anger instead of waiting until a crisis erupts.
After any sort of seclusion or restraint is usedand that is only in the most ex-
treme casesPennsylvania policy requires a debriefing so that patients and staff
can talk about the incident, figure out what may be learned from it, and use those
lessons in the treatment planning process in order to avoid similar incidents. This
also allows both staff and patients an opportunity to deal with the trauma associ-
ated with their use.
The Office of Mental Health and Substance Abuse Services is establishing a base-
line and using that to measure the incidence of seclusion and restraint periodically
in each state hospital. And the state plans to share that and other such information
publicly. Any licensed entity that provides mental health careespecially those that
are publicly fundedmust be accountable to the public. That includes accountability
about seclusion and restraint.
The legislation that has been proposed in the Senate would keep confidential any
investigations and analyses developed in the wake of a death, whereas the legisla-
tion proposed in the House would make this information public. In this regard, the
House legislation is superior. The only way things can change is if there account-
ability to the public, and if state Protection and Advocacy agencies as well as citizen
advocacy organizations know and can comment on policies, on how those policies are
being implemented or are not being implemented, and on whether the incidence of
restraint use is reported on a regular basis.
One mechanism might be under Public Law 99660, the State Mental Health
Planning Act, which requires that every state submit a mental health plan to the
Substance Abuse and Mental Health Services Administration. The plan could re-
quire information on the utilization of restraints. This information should be broken
down by state hospital, so that a pattern of utilization can emerge. The advocacy
community can then focus their attention in particular on institutions with a high
usage of restraints.
As I mentioned above, the effort to eliminate seclusion and restraints has already
been successful in at least one state hospital: for six months before Haverford State
Hospital closed, there was no use of seclusion and restraints and there was a de-
crease in the use of medication.
Aidan Altenor initiated the effort to end seclusion and restraints when he was
Haverfords superintendent; he credits Deputy Secretary Curie with providing the
impetus. He has since been working toward the same goal at Norristown State Hos-
pital, where he now serves as superintendent.
Mr. Altenor described methods, which were successful at Haverford, that can lead
to eliminating restraints.
First, as mentioned above, the use of restraints must be re-defined as a treatment
failure. As Dr. Altenor said, This is not a clinical intervention; this is tying you
to a bed.
Second, a one-hour limit must be set on the period for which a physician can write
a restraint order; the patient must then be reassessed. In Haverfords past, there
was no such time limit. Dr. Altenor noted that, at Norristown State Hospital, the
nursing staff plays a critical role in determining whether someone needs to remain
in restraints for the full time period for which the order was written. That is, a
nurse may determine that someone may be released from restraints in 10 or 15 min-
utes, although the order was for an hour.
Third, when someone exhibits behavior that the staff may consider cause for using
seclusion and restraints, staff must attempt to determine what someone is trying
to communicate and must ask how the persons treatment plan can be revised to
be more responsive to that persons needs.
25
Fourth, the staff must review with the patient any incident that has led to seclu-
sion and restraints, and must ask what to do if there is a similar incident in the
future. This is common sense, it involves listening to the consumer and saying, Oh,
thats what you want us to do; we can do that. Often, this is something as simple
as going for a walk. Dr. Altenor said that this approach has played a significant
role in eliminating the use of restraints for many people.
Dr. Altenor added that when clinicians suspend judgment about what they believe
to be the most appropriate clinical intervention and go with what the consumer
wants, everyone ends up winning. With patients who are not able to provide
straightforward feedback, clinicians must apply critical acumen to translate their
messages so that they can respond with more supportive interventions.
It is also extremely important to hold training sessions where all points of view
are represented.
At Haverford State Hospital, panel discussions among consumers, family members
and professionals were presented. Besides personal testimony, the sessions also in-
cluded data on what happens when people are in restraints, such as the increased
risk of injury to both staff and patients. Prevention was also stressed.
Dr. Altenor said that the most compelling aspect of the sessions was the con-
sumers stories about how it felt to be in restraints. Many people said that they felt
violated, and at the mercy of whoever was walking around in the room. They felt
they were being punished for aspects of their illness over which they had no control,
adding insult to injury. He said that hearing the consumers perspective was an eye-
opener.
Clearly, the consumer perspective is the most important one. We are advocating
for a national program of self-advocacy training for consumers of mental health
services, because we find that consumers make the best advocates on such issues
as the abuse of restraints. This program would be implemented through Protection
and Advocacy agencies with the assistance of the National Mental Health Associa-
tion.
We would also like to see a requirement for the establishment of consumer/family/
volunteer monitoring teams at psychiatric facilities. These teams would serve as a
vital ombudsman when situations arise in which restraints may be applied. In
Pennsylvania as in many other states, we already have peer advocates working in
state hospitals, as well as peer-run drop-in centers in hospitals.
And, as I mentioned at the beginning of my testimony, we must move away from
institutions toward community-based treatment.
I would like to talk about two of the individuals whose stories are told in an amici
curiae brief filed with the U.S. Supreme Court by the National Mental Health Con-
sumers Self-Help Clearinghouse, of which I am also executive director, and other
consumers and consumer organizations. The brief was filed in the Olmstead case,
which is a challenge to the community integration mandate of the Americans with
Disabilities Act.
Both of these individualsMargaret Donahue and James Pricespent a lot of
time in seclusion and restraints when they were residing in state hospitals. As
James Price described the conditions: It was hard living there. I had to stay in a
day room and wasnt able to get out. We had a dormitory with eight to ten people.
I got in trouble there a lot. They would put me in seclusion and restraints and give
me needles.
For the last eight years, however, he has lived in his own apartment in Philadel-
phia, and he enjoys his freedom. He does volunteer work, goes to the movies, and
has his eight-year-old niece over to stay.
Margaret Donahue also spent most of her life in institutions. She now lives in
Willow Grove, Pennsylvania, in a house she shares with two other women, both of
whom were also patients at the state hospital. The house is a supported living res-
idence, with round-the-clock staffing.
In the hospital, she reported, she spent a lot of her time in restraints because of
fighting and banging her head. In the community, she has none of those problems.
She entertains visitors, and sometimes goes to church. She also does her own house-
work, and has a part-time job cleaning houses. In her words, Its better living in
my house [than in the hospital]. You cant live in the hospital all your life.
No, you cant. But those people who do find themselves hospitalized must be as-
sured of a safe place. Toward this end, we would like to see the day when the last
available set of restraints is displayed in a Plexiglas case, under a sign saying obso-
lete equipment. We hope the proposed legislation takes us one step closer to that
day.
Thank you for your attention.
26
STATEMENT OF DENNIS OLEARY, M.D., PRESIDENT, JOINT COMMIS-
SION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS
Senator SPECTER. We now turn to Dr. Dennis OLeary, President
of the Joint Commission on Accreditation of Health Care Organiza-
tions. Dr. OLeary has served as dean of the Clinical Affairs Unit
at George Washington University Medical Center and Vice Presi-
dent of the George Washington University Health Plan.
Thank you for joining us, Dr. OLeary. We look forward hearing
from you.
Dr. OLEARY. Thank you, Senator Specter.
On behalf of the Joint Commission on Accreditation of Health
Care Organizations, I would like to thank you and the other mem-
bers of the subcommittee for holding these hearings to address the
very serious problem surrounding the improper use of physical re-
straints on patients in psychiatric facilities. We appear here today
as a very committed part of the solution to eliminating the occur-
rence of these tragic events.
Over the past half century, the Joint Commission has made sig-
nificant contributions to protecting patient rights, enhancing pa-
tient safety and reducing restraint use in the nearly 20,000 health
care organizations it accredits. Long-standing Joint Commission ac-
creditation standards cover the full range of issues relating to the
use of restraints.
These include clinical justification for use, staff training and
strategies for limiting the use of restraints. Application of these
standards has reduced the use of restraints in accredited organiza-
tions.
In 1995, patient safety became a pivotal focus of the Joint Com-
missions oversight efforts. During that year, we began an intense
effort to evaluate restraint-related deaths in accredited organiza-
tions as part of a broader initiative to gain knowledge about seri-
ous adverse occurrences in the care of patients. This initiative took
its origins in the midst of an apparent outbreak of widely pub-
licized, unanticipated serious injuries and deaths.
The existence of these serious occurrences, which we call sentinel
events, was a clarion call to the Joint Commission and others that
far greater efforts needed to be made to improve the safety and
quality of health care.
In this process, the Joint Commission has become the nations
leader in facilitating the identification of sentinel events and work-
ing with organizations to reduce the risk of future occurrences and
in sharing lessons learned. Today the Joint Commission requires
accredited organizations to identify all sentinel events and address
their underlying causes. Failure to do so places the organization for
risk of loss of its accreditation.
The Joint Commission believes that asking organizations to iden-
tify and report unexpected deaths and injuries is the first step in
the process of reducing in the incidences of sentinel events. No en-
tity charged with oversight responsibilities can take appropriate ac-
tion without this kind of information. That reporting responsibility
for restraint-related deaths must lie on the organizations where
care is being provided.
27
But if mandatory reporting of restraint-related deaths is a neces-

sity, we must recognize that it will not, by itself, be sufficient in
reaching the goal of eliminating these tragic events.
The Joint Commissions board of commissioners has taken the
position that the most effective way to reach this goal is to man-
date the reporting of restraint-related deaths as part of an over-
sight framework that also facilitates a no-holds-barred internal
self-evaluation process. However, to achieve this objective, these
root cause analyses must be protected from public disclosure by
federal legislation.
We must emphasize that the creation and sharing of these highly
sensitive documents with monitoring agencies will be resisted un-
less they are afforded a peer review-like protection similar to what
the states now have in place for hospital internal quality review.
Early this year, our board of commissioners appointed a new
high-level restraint use task force, which will conduct a thorough
reevaluation of the Joint Commissions current restraint standards,
on-site evaluation process and other means for accessing informa-
tion about restraint use. That task force is expected to make its
final recommendations to the board by the end of this year.
The task force has launched its efforts by initiating a series of
public hearings across the country. These hearings are designed to
elicit input from the public and other interested parties regarding
the current oversight process and what can be done to make it
more searching and meaningful.
We are also seeking dialogue with the health professional com-
munities, because we believe that more than just the accreditation
process must change. There must also be a significant reevaluation
of what are considered acceptable practices and behaviors in pro-
viding psychiatric and psychological care.
The reduction of restraint-related deaths and other sentinel
events is one of the most important issues facing us today. Again,
we applaud the subcommittees leadership on this issue.
PREPARED STATEMENT
We support and welcome the opportunity to bring together the

strength of the public and private sectors to address these issues.
And we look forward to working with you in doing whatever is nec-
essary to prevent other deaths from occurring.
Thank you.
Senator SPECTER. Thank you very much, Dr. OLeary.
PREPARED STATEMENT OF DENNIS OLEARY
On behalf of the Joint Commission on Accreditation of Healthcare Organizations,
I would like to thank Chairman Specter and the other members of the Sub-
committee for holding these hearings to address the very serious problems sur-
rounding the improper use of physical restraints on patients undergoing psychiatric
or psychological treatment, and I am very pleased to provide our recommendations
for appropriate action. We appear here today as a very committed part of the solu-
tion to eliminating the occurrence of these tragic events.
There should be zero tolerance for the types of deaths we have all read about in
the Hartford Courant series. Many of the 142 patients who died in relation to the
use of restraints were children and adolescents. Ms. Allens testimony about her son
is especially heart wrenching and is nothing less than a call to action for all in the
28
health care system who have not already taken serious steps to change the status
quo.
The Joint Commission views this hearing as a major opportunity to begin to build
consensus on effective safeguards for reducing the likelihood of restraint-related
deaths. This will be a daunting task, for there are few things in health care as chal-
lenging as the appropriate management of restraint use. The issues to be dealt with
go to the very heart of patient rights, patient safety, and the safety of health care
workers. Significant opportunities exist in improving staff training, identifying and
sharing best practices, and developing and using effective alternatives to restraints.
But the most immediate need is the design of an oversight framework which estab-
lishes clear accountabilities, and facilitates learning from each tragedy that occurs
without driving the reporting of such incidents underground.
Over the course of its long history, the Joint Commission has made significant
contributions to protecting patient rights, enhancing patient safety, and reducing re-
straint use in the nearly 20,000 health care organizations it accredits. We have had
extensive patient rights standards for many years that set clear expectations re-
garding personal interactions with patients, specify the information patients must
be given about their rights, and describe the physical, social, and cultural environ-
ments necessary to the effective support of patient care. Joint Commission stand-
ards have, as well, delineated requirements for patient safety, while protecting the
dignity with which patients are being treated. Professionals in the behavioral health
care field can attest to the Joint Commissions pioneering efforts in these areas over
the past several decades.
Joint Commission accreditation standards have also had a positive effect on iden-
tifying and addressing inappropriate use of restraints. While the organizations we
accredit have long evidenced difficulty in fully meeting these standards, their per-
formance has progressively improved in recent years and most behavioral health
care professionals would be quick to acknowledge their impact in reducing inappro-
priate restraint use.
Because of their high visibility and importance, the restraint standards are fre-
quently reviewed and updated in collaboration with expert professionals, advocacy
groups and other stakeholders. These standards cover a range of important issues,
including clinical justification for use of restraints, staff orientation, and education,
and strategies for limiting the use of restraintsand are more comprehensive than
comparable standards used by other accreditors, the states or the Health Care Fi-
nancing Administration (HCFA).
In 1995, patient safety assumed an increasingly prominent role in the Joint Com-
missions agenda. During that year, we began an intense effort to evaluate and mon-
itor restraint-related deaths in accredited health care organizations as apart of a
broader initiative to gain awareness and knowledge about and resolve serious ad-
verse occurrences in the care of patients. This initiative took its origins in the midst
of an apparent outbreak of widely publicized unanticipated serious injuries and
deaths. The importance of this effort to the Joint Commission lay, and continues to
lie, in the fact that our accreditation process is fundamentally designed to reduce
risk to patients. The existence of these serious occurrenceswhich we call sentinel
eventswas a clarion call to the Joint Commission and others that more needs to
be done to improve the safety and quality of health care.
Since 1995, the Joint Commission has become the nations leader in facilitating
the identification of sentinel events, in working with specific organizations to reduce
the risk of future occurrences and in sharing lessons learned with other accredited
organizations. This has been both an enlightening and sobering experience. The risk
of errors is highan inevitable correlate of the intense human effort involved in pa-
tient care, the growing complexity of care, the expectation that care be provided
with fewer resources, and other risk enhancing factorsand it appears that a sig-
nificant number of errors and even sentinel events, are not reported within organi-
zations. There is much to be done.
Today the Joint Commission requires accredited organizations to identify all sen-
tinel events and address their underlying causes. Current policy also encourages the
voluntary reporting of sentinel events to the Joint Commission, and where the Joint
Commission becomes aware of a sentinel eventeither self-reported (80 percent) or
through other sources such as the media (20 percent)the organization is required
to perform and make available to the Joint Commission an in-depth analysis of the
underlying causes and an appropriate action plan. Failure to do so places the orga-
nization at risk for loss of its accreditation. It is the Joint Commissions experience
with the sentinel event reporting program that provides us with the unique perspec-
tive we wish to share with you today, toward the end of eliminating the types of
tragedies that bring us here today.
29
The most immediate and obvious issue is that the litigious atmosphere in which
health care is provided in this country constrains the willingness of accredited orga-
nizations to self-report sentinel events and, in a very real sense, to run the risk of
self-indictment through sharing their sentinel event analysis with a private sector
accrediting body. With these concerns in mind, the Joint Commission sought federal
legislation last year to protect these analyses. We were particularly pleased to have
our legislative initiative supported by the Leadership of the House of Representives
and subsequently passed by the House in last years Patient Protection Act.
But even stronger medicine is needed to bring these tragic occurrences to the sur-
face and deal with them. Our understanding of the complexities and sensitivities at-
tending effective reporting programs leads us to be very supportive of the manda-
tory reporting provisions for restraint-related deaths contained in Senators
Lieberman and Dodds Freedom from Restrain Act of 1999 (S.736) which incor-
porates and expands upon the important strategic concepts in the Patient Protection
Act respecting sentinel event reporting. We believe S. 736 would provide the ground-
work for a public/private sector partnership that could strengthen the value of vol-
untary accreditation in promoting patient safety and extend the most successful as-
pects of the sentinel event program to non-accredited health care organizations par-
ticipating in Medicare and Medicaid.
REPORTING
Reporting unexpected deaths and injuries is the first step in the process of reduc-
ing the incidence of sentinel events. Obviously, no entity charged with oversight re-
sponsibilities can act without information. Reporting should be the responsibility of
the organizations experiencing the sentinel events, and reporting should be encour-
aged and rewarded. Creating inventories of serious medical events should not fall
by default to investigative reporters. The Hartford Courant series shocked us all by
describing the magnitude of restraint-related death over a decade long period. These
deaths occurred in a multitude of facilities being overseen by a number of different
bodiesthe states, through Medicaid or licensure programs; HCFA for all Medicare
facilities; local government programs; the Joint Commission, and others. Yet none
of us had an accurate compilation of all the restraint-related deaths that occurred
under our respective auspices.
Seventeen states have instituted mandatory reporting programs for serious
events, but even health officials in Massachusettsone of the states with the
strongest reporting laws in this countryhave acknowledged that they rely on the
press for most of their information. This is an unacceptable way to get information
about the least tolerable outcomes in our health care system. As noted, the Joint
Commissions sentinel event reporting system is voluntary rather than mandatory,
and restraint-related deaths are the fifth most commonly reported type of sentinel
event. With over 400 sentinel event cases now in our database, we are proud of the
willingness of so many health care organizations to report and act upon their seri-
ous events. Yet regrettably, even our program did not have a record of all of the
deaths detailed in the Hartford Courant series that occurred in accredited organiza-
tions since 1995.
If we cannot fully rely upon the completeness of reporting systems where they do
exist, how do we improve upon the reporting and resolution of these tragic events
which have now become a significant public policy concern in health care? The Joint
Commissions Board of Commissioners has taken the position that the most effective
way to address this need is to mandate the reporting of restraints-related deaths
as part of an oversight framework that also facilitatesthrough protection from dis-
closurethe collection and review of root cause analysis information, from the re-
sponsible health care provider organizations, by accountable oversight bodies. These
conditions are a sine que non for gaining a true understanding of underlying causes
and developing appropriate preventive measures for the future.
ROOT CAUSE ANALYSIS INFORMATION
Requiring the conduct of substantive, in-depth analyses for each sentinel event
root cause analysesis the next critical step to reduce the incidence of restraint-
related deaths. This step introduces the critical goal of risk reductionthat is, re-
ducing the likelihood that a similar death will occur for similar reasons in the same
institution. Without this key step, reporting becomes the end game, and there is lit-
tle evidence that mandatory or voluntary reporting of health care sentinel events,
by itself, has led to improved patient safety or quality of care. The opportunity for
improvements can only be created by a thorough, careful analysis of what went
wrong. As noted, Joint Commission accredited organizations are required to perform
a root cause analysis after the occurrence of each sentinel event.
30
Root cause analysis is a concept borrowed from the field of engineering. It in-
volves a systematic evaluation of what processes failed and led to an unexpected
outcome. In a given case, a root cause analysis would elucidate all factors contrib-
uting to a restraint-related death. It helps identify any system changessuch as re-
view of staff competencies or trainingthat must take place to remedy any system
failures that led to one of these tragedies. Coupling mandatory reporting with a re-
quirement to learn and act would create powerful leverage toward reducing or elimi-
nating restraints-related deaths. And for the vast majority of health care organiza-
tions which want to do the right thing, this approach would provide tangible guid-
ance toward making changes in their organizational processes to prevent future oc-
currences of restraint-related deaths.
Therefore, we support federal legislation that will recognize root cause analyses
as an essential risk reduction activity which must be sufficiently protected from
public disclosure to permit a completely honest, no-hold-barred approach to inter-
nal, self-evaluation. These analyses, once put on paper, become highly sensitive doc-
uments, and their creation and sharing with monitoring agencies will be resisted
unless they are afforded a peer review-like protection, similar to what states now
have in place for hospital internal quality review. We cannot emphasize strongly
enough that any federal legislation aimed at increasing reporting of restraint inci-
dents must include provisions to protect these specific documents. Otherwise, root
cause analyses will not be adequately doneor done at alland we will not make
the essential progress toward preventing human tragedies.
PERFORMANCE MEASUREMENT
Restraints oversight also lends itself to preventive monitoring as a part of the

emerging new quality measurement initiatives. The Joint Commission has also been
a leader in this area, and is proud of its ORYX initiative that requires accredited
organizations to submit quarterly performance data as part of a new continuous
monitoring and evaluation process. We believe that ORYX holds significant promise
for assisting organizations in monitoring and if appropriate altering their restraint
use. There are currently 26 performance measures related to the use of restraints
or seclusion that are now available for use by hospitals under ORYX. Six of these
measures have been selected for quarterly reporting to the Joint Commission by in-
dividual accredited hospitals. They range in nature from measuring the prevalence
of daily restraint use to reporting the actual percentage of restraint hours. Accred-
ited nursing homes are also using some of the ORYX restraint-related measures for
long term care. We have already received some feedback from accredited organiza-
tions that the use of ORYX measures has helped them improve their restraint use.
PUBLIC ACCOUNTABILITY
Public accountability through public reporting of restraint-related deaths provides

a final strong lever to the reduction of future occurrences. The occurrence of a re-
straint-related death should not be kept either from the public or from those with
quality oversight responsibility. These occurrencesin the most vulnerable of indi-
vidualsrequire immediate attention and, almost always intervention. Organiza-
tions can underscore their own commitment to change by publicizing the interven-
tions taken following a restraint-related death.
The public should also expect that the oversight bodies responsible for monitoring
restraint-related deaths will, through their own mechanisms, use their measure-
ment information to identify and disclose poor performers to the public. Bad
things happen, even in health care organizations otherwise providing good health
care. However, a pattern of poor performance or a documented resistance to resolv-
ing quality or safety problems that place patients at risk for further serious occur-
rences should not be kept from the public. The Joint Commission has taken an ag-
gressive approach to public disclosure for some time, and makes performance re-
ports on individual accredited organizations available to the public at no charge.
BEST PRACTICES
There is another type of information-sharing that must be an essential part of any

strategy to eliminate restraint-related events. When root cause analysis information
is shared with oversight bodies, a powerful source of information on appropriate,
and even best, practices is continually being created and expanded. The Joint Com-
mission is already credited with saved lives by alerting health care organizations
about dangerous practices that have come to light under our sentinel event pro-
gram, and suggesting ways to prevent future sentinel events. A case in point is our
experience in guiding hospitals in the appropriate storage of potassium chloride.
After identifying a pattern of deaths across the country resulting from the inad-
31
vertent administration of concentrated potassium chloride as a result of packaging
and labeling confusion, we alerted all accredited facilities to limit access to this po-
tentially lethal solution. We also have issued a sentinel event alert on the issue of
restraints, advising providers about effective alternatives to the use of physical re-
straints and the importance of seeking less restrictive measures to achieve treat-
ment and safety goals.
JOINT COMMISSION COMMITMENT
This testimony began with a statement about the Joint Commissions commitment
to reducing the number of restraint-related deaths in this country. That commit-
ment is backed by a long-standing and continuing role in setting standards for pa-
tient rights and for the use and monitoring of restraints, and more recently, by the
Joint Commissions leadership role in facilitating the identification of sentinel
events, working with organizations to reduce the risk of future occurrences, and
sharing lessons learned with all accredited organizations. But the Joint Commis-
sion does not intend to end its commitment there.
Early this year, our Board of Commissioners appointed a new high-level Restraint
Use Task Force which will conduct a thorough re-evaluation of the Joint Commis-
sions current restraints standards, on-site evaluation process, and other means for
accessing information about restraints use. That Task Force is expected to make its
final recommendations to the Board of Commissioners by the end of this year.
The Task Force launched its efforts last month by initiating a series of public
hearings across the country. These hearings are designed to elicit input, both oral
and written, from the public and other interested parties on their perspectives on
the current oversight process and what can be done to make it more searching and
meaningful. We are also seeking the input from the health professional commu-
nities, both separately and at these hearings, because we believe that more than
just the accreditation process must changethere must be a significant change in
what is considered acceptable practices and behavior by the entire community in-
volved in providing psychiatric and psychological care. The first two hearingsin
San Francisco and Atlantawere extremely well attended and rich in the input pro-
vided. Interest in the third hearing, which is taking place in Alexandria today, is
so great that we have had to divide it into two separate sessions. We should take
great heart in the evident broad commitment of all of the parties at interest to close
down one of the most sordid chapters on health care in this century.
CONCLUSION
The reduction of restraint-related deaths and other sentinel events is one of the
most important issues facing us today. Again, we applaud the Subcommittees lead-
ership on the issue. We support and welcome the opportunity to bring together the
strength of public and private sectors to address these issues, and we look forward
to working with you.
STATEMENT OF THOMAS HARMON, EXECUTIVE SECRETARY, MEDICAL

REVIEW BOARD, NEW YORK STATE COMMISSION ON QUALITY
CARE
Senator SPECTER. We turn now to Mr. Thomas Harmon, Execu-
tive Director of the Medical Review Board of the New York State
Commission on Quality Care.
Thank you very much for joining us, Mr. Harmon. We note your
20 years work on supervising investigations of over 4,000 cases of
abuse and deaths in mental health facilities. The floor is yours.
Mr. HARMON. Chairman Specter, Senator Harkin and others,
thank you for this opportunity to speak on the matter of inde-
pendent investigations into deaths in mental hygiene facilities, par-
ticularly deaths in which restraint or seclusion was a factor.
As noted, I work for the New York State Commission on Quality
of Care, which is New York States protection and advocacy agency.
The commission has often been cited as a model for independent
investigations. Most recently, the Hartford Courant series on dead-
ly restraint lauded New York State as being one of the few states
32
requiring the reporting of all mental hygiene consumer deaths to

an independent body for review and investigation.
I want to share with you my perspectives on what makes New
York State unique and the value of the independent death inves-
tigations we conduct. The commission was created in 1977 by state
law in New York to oversee programs serving the mentally dis-
abled. Among other things, the law in New York required that all
deaths and allegations of abuse be reported to our commission so
that we can review and conduct investigations where necessary.
It was subsequent to that that we became New York States fed-
erally designated protection and advocacy agency. However, in cer-
tain respects, New York State law confers upon the commission
greater authority than most P&As are afforded under the federal
laws.
For example, whereas New York State law requires that all
deaths and allegations of abuse be reported to the commission, and
we can then commence an investigation, most other P&A agencies
do to receive that notification and can only commence an investiga-
tion when they receive a complaint or they have suspicion of abuse.
Let me cite two values of independent death investigations. The
first is impartiality. All facilities, either by law, regulation or the
mandates of their accrediting bodies, are required to conduct inter-
nal investigations of untoward events for the purpose of protecting
their patients and consumers from future harm. And a lot of facili-
ties endeavor to do that.
However, there are a number of factors which erode facilities
ability to do that faithfully, or erode the publics confidence in their
ability to do it. Facilities in their investigative zeal may be quick
to find and remedy the obvious smoking gun, like an employee
error, for example, but not take the time to look at the underlying
issues which set the employee up for that error. In facilities where
serious events happen, very infrequently the facility may lack the
requisite skills to investigate the matter as much as they des-
perately want to get to the bottom of what went on.
And sometimes it may be perceived that the facilitys investiga-
tion is self-serving, and confidence in its results is reduced. The
primary value brought by independent investigations is their im-
partiality. We have no self-interest to serve.
And as often as the commission has found problems in cases we
have investigated and deaths that we have investigated, we found
an equal number of cases, if not greater, where a death, as unex-
pected as it was, did not suggest problems in care. And we were
able at that point in time to give the family and the facility alike
some peace of mind in an otherwise discomforting time.
Finally, let me just say another value. And that is, independent
investigations can go and bring lessons to beyond the walls of the
facility where you are investigating. I have in my written testi-
mony an example of where we investigated a death on Long Island,
where towels were used to protect staff from biting and spitting.
And the facility terminated that practice after we brought the haz-
ards of that practice to its attention.
But when we learned that it was happening at other facilities in
the state, we brought it to our state office of mental health, which
33
in February issued an alert to all hospitals across the state to ter-

minate the practice.
In closing, I wanted to bring to you the commissions experience
in conducting death investigations with the hope that it can be a
model for other states, as you deal with this problem of restraint
and seclusion deaths.
Thank you.
Senator SPECTER. Thank you very much, Mr. Harmon.
PREPARED STATEMENT OF THOMAS HARMON
Chairman Specter, Senator Harkin and other Senators, thank you for this oppor-
tunity to provide testimony on the matter of independent investigations into deaths
of individuals who are residents or patients of mental hygiene facilities, particularly
deaths in which restraint or seclusion was a factor.
My name is Tom Harmon and I work for the New York State Commission on
Quality of Care, New York States designated agency within the federal Protection
and Advocacy system. For over 20 years, the Commission on Quality of Care has
conducted investigations into deaths, and other matters, within mental hygiene fa-
cilities. The Commission has often been cited as a model for independent investiga-
tions and most recently, in the Hartford Courants October 1998 series Deadly Re-
straint, New York State was lauded as one of the few states requiring the reporting
of all mental hygiene consumers deaths to an independent agency for review and
investigation. Having spent the majority of my twenty years with the Commission
coordinating its death investigation activities, I want to share with you my perspec-
tives on what makes New York State unique, the value of independent death inves-
tigations, and some of the key ingredients for a successful death investigation proc-
ess. To supplement my testimony, I am also submitting written materials which am-
plify or further illustrate points I raise including the Commissions enabling legisla-
tion (Article 45 Mental Hygiene Law) and several reports published by the Commis-
sion which I believe you will find helpful.
NEW YORKS UNIQUE SITUATION
Among the nations P&As, New York States is unique. In the mid-1970s, New
York State recognized the need for independent oversight of facilities serving its
most vulnerable citizensindividuals with mental disabilities. And, with the enact-
ment of Chapter 655 of the Laws of 1977, the Commission on Quality of Care was
created. Among other things, the law required that all deaths and allegations of
abuse occurring in mental hygiene facilities be reported to the Commission for its
independent review and investigation. In subsequent years, the Commission was
designated as New York States P&A agency; however, in certain respects, New
York State law confers upon the Commission greater authority than most P&A
agencies are afforded under federal law.
For example, whereas NYS law requires that all deaths be reported to the Com-
mission in a manner and form prescribed by the Commission and allows the Com-
mission to commence an investigation where deemed indicated, other P&As do not
receive such notification and can only commence an investigation when they receive
a complaint or have reasonable cause to suspect abuse.
THE VALUE OF INDEPENDENT DEATH INVESTIGATIONS
Time constraints prohibit me from extolling all the values of independent death
investigations. But allow me to propose two chief ones. The first, in my opinion, is
impartiality. All facilities, by mandates of law, regulation or accrediting bodies, are
expected to engage in a process of risk management, critical self- examination or
quality assurance, around untoward events in order to protect the individuals they
serve from future harm. A great many facilities endeavor to fulfill this obligation
faithfully. However, there are a number of factors which may erode even the best
facilities abilities to exercise this duty or may erode the publics confidence that it
has been fulfilled, particularly with regard to the most serious of untoward events:
an unexpected, sudden death or deaths related to restraint. Facilities in their inves-
tigatory zeal may be quick to find and remedy the obvious smoking gun, an em-
ployee who erred, for example, without taking the time to examine underlying sys-
temic issues such as staff training, supervisory policies, and staffing allocations. In
facilities where serious events happen infrequently, the facility may lack the req-
34
uisite skills to conduct an effective investigation, no matter how desperately it
wants to.
The primary value brought by independent investigations into the most serious
of untoward events is their impartiality; independent investigators have no self-in-
terest to serve by their investigations. As often as the Commission has found that
certain deaths suggested problems in care, we have found, in an equal or greater
number of cases, that the death, perhaps as unexpected as it was, did not suggest
problems; the Commissions impartial investigations found care was appropriate,
thereby offering families and facilities alike some peace of mind in an otherwise dis-
comforting time.
A second value of independent investigations, particularly those done by a single
agency, is the opportunity for systemic reform or system-wide protection and pre-
vention. During a recent investigation into a death on Long Island, the Commission
found that facility staff would routinely hold a towel snugly over the mouths of pa-
tients they restrained. When advised by the Commission of the inherently dan-
gerous nature of this intervention, the facility terminated the practice. However, the
Commission learned that this practice was employed at other hospitals and brought
the matter to the attention of our State Office of Mental Health which recently
issued a statewide alert banning the technique. Additionally, the Commission put
OMH in contact with the New York State Office of Mental Retardation and Develop-
mental Disabilities to further explore a safer device employed by an OMRDD facility
for preventing spitting or biting hazards during restraints.
The above example illustrates the value brought by an independent investigating
body working collaboratively with regulatory agencies to bring about systemic re-
form, each propelling the other into finer and finer consumer service and protection
practices. Other examples of these collaborative efforts include:
In the early-1990s, our Office of Mental Health conducted an extensive review
of restraint and seclusion practices in New York State and issued new policies
on this subject, resulting in a reduction of the utilization of these interventions;
Our Office of Mental Retardation and Developmental Disabilities has developed
a rigorous protocol for approving and routinely monitoring the use of certain re-
strictive interventions; and
Both regulatory agencies have developed training programs on the use of re-
straint, seclusion and physical interventions which emphasize alternatives to
such interventions and tools to de-escalate situations to thereby reduce the need
for their use.
While not all cases may suggest the need for system-wide reforms, many cases
present opportunities to revisit staff training programs or reexamine and refine poli-
cies or procedures at individual facilities across the state. In this vein, the Commis-
sion has had much success with a series of case studies it produces for all facilities
in New York State entitled, Could This Happen In Your Program? The series pre-
sents actual cases investigated by the Commission and invites readers to reflect on
their own agencies operations and whether lessons learned elsewhere have applica-
bility in their programs. These training materials provide managers and direct care
staff an opportunity to examine their own operations to prevent similar tragedies
from occurring in their facility.
KEY INGREDIENTS
Realizing the benefits of independent investigations requires that the inves-

tigating body has all the needed tools. Id like to briefly list some of the tools which
have enabled the Commission to establish a noteworthy investigation process in
New York State.
Understanding why a person died and whether the death suggests ways in which
care can be improved is like putting together a puzzle. First, you need to have all
the pieces; including not just information from the mental hygiene facility, but
records and other information from, among others, coroners, medical examiners,
general hospitals where the individual may have died or been treated, law enforce-
ment personnel and Emergency Medical Services crews. Accessing this information
in a timely fashion is important and, in New York State, the Commissions right
of access is spelled out in State statute.
Once all the pieces have been amassed, one also needs individuals sufficiently ex-
pert in putting the pieces together and interpreting the picture which emerges. The
Commission has nurses on staff who review the medical cases we investigate. But
sometimes situations arise which require more detailed clinical analysis. The legis-
lation establishing the Commission also provided for a Medical Review Board con-
sisting of volunteer physicians, appointed by the Governor, to assist the Commission
on a volunteer basis on matters it investigates. The physicians have specialties in
35
Forensic Pathology, Psychiatry, Surgery, Internal Medicine, and Pharmacology.
Over the years their expertise has been of great value to the Commission, and the
people we serve, in helping to assemble the pieces of the puzzles we are called on
to solve and offer meaningful recommendations to protect the living.
In closing, I believe the Commissions independent investigations into unusual
deaths and incidents of abuse, in collaboration with the efforts of our States Office
of Mental Health and Office of Mental Retardation and Developmental Disabilities,
have led to important improvements in the quality of care afforded individuals with
disabilities and could serve as a model for other states in their efforts to protect and
best serve their most vulnerable citizens.
Once again, I wish to thank you for the opportunity to testify before you today.
[CLERKS NOTE.The written materials referred to in Mr. Har-
mons statement do not appear in the hearing record but are avail-
able for review in the subcommittee files.]
Senator SPECTER. Mr. Rogers, would you bring those devices up
so Senator Harkin and I can take a closer look at them?
Mr. ROGERS. It is a straightjacket.
Senator SPECTER. Straightjacket? Bring that up. Let us take a
look at that.
Senator HARKIN. I have never seen a straightjacket in my life.
Senator SPECTER. Senator Harkin says he has never seen a
straightjacket. How do you put this on?
Mr. ROGERS. Well, you put it on so usually your arms go back
in the back. This one
Senator SPECTER. The arms in the back?
Mr. ROGERS. Yes; I have not practiced this one. This one, your
arms would just be inside, and the whole thing would be strapped
around you so you could not make any moves at all.
Senator HARKIN. Oh, I see.
Senator SPECTER. Let us see how the others work. These are for
hands and
Mr. ROGERS. Right. These would restrain you by strapping your
arms down to a gurney or to a chair, wherever they want.
Senator SPECTER. Come around here and show us how this would
be applied.
Mr. ROGERS. All the way over there?
Senator SPECTER. Right here is fine.
Mr. ROGERS. Well, you take the individual, and you strap them,
you work the strap through.
Senator HARKIN. What is all this stuff over here?
Mr. ROGERS. This is an interesting thing. This is a net they use.
Senator SPECTER. Before you do that, show us how these work.
Mr. ROGERS. And then you pull them down, and they strap to a
chair or to a bench or whatever. Unfortunately, sometimes they
strap you to a gurney, and that is actually a very dangerous prac-
tice. Because if the person gets violent, throws themselves around,
the gurney can flip over. And if they are not being observed, the
gurney lands on top of them, they can literally break their neck.
Mr. ROGERS. This they use by really throwing it over a person.
And they can strap them down.
Mr. HARKIN. You have got to be kidding me.
Mr. ROGERS. This is used to, again, put the arms through. And
then you canthis can hold the person totally down on whatever
you set them down on, a gurney or onto a bed. And the idea is to
hold them. Unfortunately, what happens in a lot of cases is the
person is really upset and disturbed, obviously. You put them in
36
the restraints. They are sometimes put in way too tight. Their abil-
ity to breath, their ability to aspirate, is affected. And that is what
causes a lot of the deaths.
Senator SPECTER. OK. Thank you very much, Mr. Rogers.
Senator HARKIN. It is like some kind of a torture movie, you
know, like movies you see in wartime when they torture people.
That is what it looks like.
Mr. ROGERS. Well, when the movies want to make a dramatic sit-
uation, they use these restraints. And it is pretty dramatic what
it does to a person.
In my case, I came into the hospital for help, was not really that
agitated. For some reason, the staff decided that I needed to be re-
strained. I can tell you, it took me a long time to go back to the
hospital for help after having had that done.
Senator HARKIN. I can believe that.
Mr. ROGERS. Thank you, Senator.
Senator HARKIN. Well, thank you very much.
Senator SPECTER. Dr. OLeary.
Dr. OLEARY. Yes, sir.
Senator SPECTER. Beginning the questioningand Senator Har-
kin and I will each take five-minute rounds and go to 10:30is it
realistic to have a requirement that there not be any restraint ex-
cept on a doctors order? That is one of the suggestions made in the
legislation which is pending. And that seems like a very good way
to limit these kinds of restraints which are so brutal to issues of
absolute necessity. There is an exception in emergency situations
where then a doctor would be called in with as prompt as possible
review of it. But is it realistic to impose that kind of requirement
on the use of these restraints?
Dr. OLEARY. I think that it is a realistic requirement and, more
than that, a necessary requirement.
Senator SPECTER. So you would endorse that.
Dr. OLEARY. Yes; I really would. And I think the issue that actu-
ally is being begged is whether restraints should be used in any sit-
uations other than in an emergency situation. I think that is one
of the issues that we all need to be looking at very seriously.
Senator SPECTER. Well, that would be quite a remedy, to require
a doctor to authorize it. And maybe there could even be some provi-
sion on an emergency basis to require a doctor to review it, if that
could be set up. We would have to examine that.
Mr. Harmon, you have in your resume stated that you have dealt
with some 4,000 cases of abuse and deaths. How many of those are
deaths?
Mr. HARMON. Oh, in the past 10 years, working for a medical re-
view board, I probably have looked at 2,000 to 3,000 deaths in New
York State.
Senator SPECTER. I join my colleagues in the compliment for the
Hartford Courant. It is a phenomenal series. And it is in the great
tradition of American investigative journalism to make a disclosure
of this sort, which focuses congressional attention. Once we are ac-
quainted with the problem, then we can move ahead to try to fash-
ion an answer to it.
37
The estimates are about 150 deaths a year. But given the statis-
tics of what you have worked on in New York State alone, it seems
to me that that kind of an estimate is very, very understated.
Would you haveI see nods from Dr. Allen and Dr. Mohr. Would
you have an estimate as to the number of deaths which result from
excessive restraints in this country on an annual basis?
Mr. HARMON. Not nationally. I can say in New York State last
year, in 1998, we received at our commission approximately 170 al-
legations of abuse or neglect involving restraints. And
Senator SPECTER. Did those result in deaths?
Mr. HARMON. In four cases, there were deaths. So we had four
deaths in 1998. In two of those cases, I think, I know, that upon
investigation, we could find no problems in care. In the other two
cases, there were problems.
Senator SPECTER. And the speculation is there would be a great
many more unreported.
Mr. HARMON. No. I do not believe in New York State
Senator SPECTER. You think they do report them there.
Mr. HARMON. By law, they have to. And we also require them to
fill out forms that indicate whether or not restraint was used with-
in a 24-hour period of
Senator SPECTER. Well, I suspect that notwithstanding tight re-
porting requirements, that a lot are unreported. People have a
tendency not to report when the information might lead to liability
on their part. I do not want to impugn your report as in New York
State, but my experience would suggest that.
Dr. Allen, listening to the case of your son, absolutely horrible,
and we all sympathize with you. Having had 16-year-old sons my-
self, I can understand and appreciate your anguish. As you have
related the circumstance, there was more than carelessness.
There was a degree of recklessness, which really crosses the
homicide line. What you have stated goes to involuntary man-
slaughter. And perhaps recklessness in the extreme can constitute
malice for murder in the second degree.
You may not want to answer this question now, but I would like
you to give some consideration, and the other panelists as well, as
to whether legislation ought to have criminal sanctions attached to
it, as well as licensing and reporting. I see a lot of nods in the audi-
ence. If you get a little tougher, you may find a little more deter-
rence. But the case you describe really shrieks out for a degree of
recklessness, which is homicide.
What do you think, Dr. Allen?
Dr. ALLEN. Certainly I think there has to be a degree of account-
ability. And we can have national standards, and we can have bet-
ter training. But I agree with you, sir, that perhaps there needs to
be a deterrent.
Senator SPECTER. Dr. Mohr, one final question. My red light is
on. I am very much impressed with your comment that it is a psy-
chiatric convention contrasted with a psychiatric necessity. On a
broader educational picture, how do we tell the people of America,
who are in this field, the workers, those who are there, what the
appropriate standards are beyond doing what is conventional and
so damaging? What can be done to educate us to what really is
medically necessary?
38
Dr. MOHR. I think there is two parts to your question. Number

one, we do not really have a good research foundation. So we have
no good programs to teach people. We have promising practices.
And what I would recommend is to teach people what our prom-
ising promises are, people in the profession and in our schools,
what our promising practices are, and then to continue to do re-
search to see whether we can just simply do better.
Senator SPECTER. Thank you very much, Dr. Mohr.
Senator Harkin.
Senator HARKIN. Again, I want to thank all of you for being here
and for your excellent testimony. I especially want to commend for
the record, Mr. Rogers, your quotes from, if I can find it here, your
home state, Mr. Chairman, a Mr. Curie.
Mr. ROGERS. Yes; from Pennsylvania, Deputy Secretary Curie.
Senator HARKIN. I do not know his position. What is his position?
Mr. ROGERS. He is the Deputy Secretary for Mental Health in
the Department of Public Welfare.
Senator HARKIN. You said that Pennsylvanias experience proves
that the use of seclusion and restraint can be eliminated or greatly
reduced when there is a treatment environment that focuses on the
strengths of the individuals being served, that protect patients dig-
nity, comfort and privacy, et cetera. You said the options available
today make the elimination of seclusion and restraint an extremely
realistic goal.
Anyway, I
Mr. ROGERS. Yes; Secretary Curie, who is the Deputy Secretary,
Department of Public Welfare, has made it almost a personal cam-
paign of his to really review what the state is doing when it uses
restraints in their state hospitals. And in one case, in Haverford
State Hospital, which is just outside of Philadelphia, they elimi-
nated, six months prior to the closing of the hospital, they elimi-
nated all use of restraints.
It is really possible, if you really look at how people are using
it, what the practices are, why they are using it, and to put some
real standards in and to have leadership, you know, being held ac-
countable to move to the point where you have tons of incidences
of restraints to nearly zero incidents.
Senator HARKIN. Dr. Allen, again, you talked about the impor-
tance of staff training, certification, that type of thing. And it has
pointed out that only three states have licensing and training
standards. Just a little bit more elaboration for me. What do you
think ought to be included in something like that? And could we
address that at the national level?
Dr. ALLEN. Truly, I do not know if training can be addressed at
the national level. I think that needs to be addressed at the indi-
vidual state levels. But I think we need to look at the need for re-
straints, or the use of restraint, as being viewed as a system failure
and not a patient failure. And staffers have to be trained, and they
have to understand. I mean, I think they have to be trained on de-
escalation techniques other than manhandling and wrestling a
child or an individual down to the floor.
But I think staff also must understand not just what to do, but
why they are doing it and how that can be effective. And I think
that staffers have to be taught that. And they must see their job
39
as facilitating the patients regaining their own self-control while

maintaining a sense of dignity, and not punishing them for being
out of control.
Senator HARKIN. Right. That is what Mr. Curie was saying. He
is talking about deescalation techniques and that type of thing,
which I am not all that familiar with.
Mr. ROGERS. What we find is that if you have an institution
where treatment is the primary thing, not just custodial care,
where people are really evaluating what the individual needs, you
do not end up using restraints. Restraint happens because, in a lot
of situations, all they are doing is providing sort of a custodial care.
It is like a jail.
So people get into trouble. Staff gets into trouble. And people get
hurt. And what we need to do is create a different standard and
a different method of treatment for people.
And restraints, if we eliminate restraints or eliminate that op-
tion, it actually has the impact of people having to find other op-
tions to deal with people. Deescalation is a technique of, when I am
confronting somebody and they are coming back at me, if I come
back at them harder, then we get into a fight. If I find ways to step
back, talk slower, quieter, I can usually bring the situation down.
Senator HARKIN. I just have to believe, just looking at these
macabre devices that you showed us here, that just coming at
someone with something like that is enough to instill fright and ap-
prehension and can lead to all kinds of reactions in an individual.
I mean, how would you feel, how would anyone in this audience
feel, if someone came at you with one of those and was going to
put you in one of those? I mean, man, you have to have some kind
of drastic emotional reaction to that.
Mr. ROGERS. Especially since a lot of people that are psychiatric
patients have histories of abuse in their childhood.
Senator HARKIN. Sure.
Mr. ROGERS. And what happens is that just triggers in them
you are talking about people that are veterans, that have faced
abusive situations and have trauma, post-traumatic syndrome.
They are going to react. You come at them like that, they are going
to fight back. And unfortunately, people get hurt.
Senator HARKIN. One thing I would like to clear up, though, I
think, Dr. Mohr, you kind of touched on that, is that there is a gen-
eral perception that restraints and these kinds of devices are used
only for people with mental disabilities. But you have pointed out
that they are used often with people with other types of disabil-
ities. Would you elaborate on that a little bit, please?
Dr. MOHR. What I can elaborate on is to reiterate what I have
said, that restraints are a convention. They are a psychiatric con-
vention, and they are a way of maintaining patient and milieu con-
trol. They are not by any stretch of the imagination in my mind
therapeutic. They are used in psychiatric facilities, and they are
used with the developmentally disabled and frequently used inap-
propriately.
Senator HARKIN. I see my time is up. Just one last thing. We are
looking at what we can do here legislatively. And, Dr. OLeary,
what will the Joint Committee on Accreditation of Hospitalsnow
40
you are going to start looking at this and what you could start
doing, right?
Dr. OLEARY. Yes; now we think there are real opportunities for
improvement here. I think the Pennsylvania model is an excellent
example of the things that can be done to really reduce restraint
use. Pennsylvania has actually been using the Joint Commission
standards and some of the new measurement techniques to focus
attention on restraint use.
So we are going to do, I think, some major things to improve the
oversight process.
Senator HARKIN. Would you keep us advised of that?
Dr. OLEARY. We certainly will do that.
Senator HARKIN. Thank you.
Senator SPECTER. Thank you very much, Senator Harkin.
Thank you very much, all. Again, I commend the Courant for the
investigative reporting which has focused on the issue.
And we are going to be taking a very close look at the require-
ment that a doctor would have to authorize the restraints and
some checks and balances as to the types of restraints and the du-
ration, and perhaps even a closer look at whether there ought to
be some criminal sanctions applied in the egregious cases which
really move from negligence to recklessness, which could be a man-
slaughter charge or even more. But I think this has been a very
informative session.
And I thank my colleague, Senator Harkin, for his work and Sen-
ators Dodd and Lieberman for their leadership on this important
field.
CONCLUSION OF HEARING
Senator SPECTER. Thank you all very much for being here, that
concludes our hearing. The subcommittee will stand in recess sub-
ject to the call of the Chair.
[Whereupon, at 10:35 a.m., Tuesday, April 13, the hearing was
concluded, and the subcommittee was recessed, to reconvene sub-
ject to the call of the Chair.]
MATERIAL SUBMITTED SUBSEQUENT TO
CONCLUSION OF HEARING
[CLERKS NOTE.The following material was not presented at the
hearing, but was submitted to the subcommittee for inclusion in
the record subsequent to the hearing:]
NONDEPARTMENTAL WITNESSES
PREPARED STATEMENT OF THE AMERICAN PSYCHIATRIC ASSOCIATION

This statement is submitted for the record by the American Psychiatric Associa-
tion. The APA is the national medical specialty association representing more than
41,000 psychiatric physicians nationwide. Our members work and practice in all set-
tings, including public and private hospitals, private practice, group practice, re-
search programs, and academia.
First and foremost, APA commends the Subcommittee for holding this hearing on
the use of seclusion and restraint. We deeply regret, however, that we were in effect
uninvited from public testimony and were thus not allowed to testify in person.
While we understand the severe time constraints that limited the hearing time to
one hour, we must note that the public hearing on this volatile, complex, and highly
emotional issue was clearly unbalanced, particularly given the fact that not a single
psychiatristthe physicians on the front line of treatmentwas allowed to testify.
It is absolutely vital that public hearings provide an opportunity for clinicians,
Members of Congress, patient advocates, and patients/consumers to sit down to-
gether and discuss vital patient care issues. It is our hope that a dispassionate ex-
amination of restraint (and of seclusion), including deaths and serious injury caused
by restraint (or seclusion), will further APAs overarching objective of ensuring the
provision of all medically necessary treatment of psychiatric patients in an environ-
ment that is safe and humane for patients and for staff.
CONGRESS SHOULD FIX THE PROBLEM WITH RESTRAINT USE WHEN IT UNDERSTANDS
THE CAUSE
The spate of recent news stories (e.g., Hartford Courant, Fox Files) has focused
public attention on the care of psychiatric patients in the inpatient or residential
setting. As a matter of general principle, APA, of course, believes that seclusion or
restraint should not cause patient deaths.
The stories in the press are lamentable, and we reiterate that seclusion or re-
straint should not cause deaths. Efforts to increase the safety of seclusion and re-
straint and to decrease deaths caused by these interventions must be based on a
clear understanding of the causes of deaths and serious injury. Precipitous action
(for example, regulatory changes) prior to a full examination of the factors leading
to safety problems may have unintended negative consequences without any im-
provement in safety.
For example, it is not clear at this time:
How many psychiatric patients were in inpatient or residential treatment set-
tings?
How many of those patients were secluded or restrained?
For how long were patients secluded or restrained? Were the facilities JCAHO
accredited? State licensed?
What post-event root cause analyses took place?
What were the results of those analyses?
What is the incidence of patient-to-patient assaults during this period? Patient-
to-staff assaults?
These are but a few of the questions that we believe must be answered in order
to determine what shortcomings now exist in the federal regulatory and JCAHO
processes as well as in current clinical standards of care.
(41)
42
PROBLEMS WITH RESTRAINT AND SECLUSION MUST BE SEEN IN THE CONTEXT OF THE
PATIENT POPULATION AND THE FACILITIES IN WHICH THEY ARE TREATED
It is vital to note that the incidence of use of seclusion and restraint, and particu-
larly deaths or serious injuries caused by such use, cannot be viewed in the abstract
but must be seen in the clinical context in which treatment occurs.
Psychiatric facilities today face unprecedented challenges. Whether by managed
care or by more traditional health insurance, there is great pressure not to admit
patients to the more expensive inpatient setting unless there is simply no alter-
native. That means that the patients we see in these settings are more seriously
ill than ever before. Manyperhaps mostare in the acute stages of their illness,
and their underlying illnesses are more likely to be severe.
At the same time, psychiatric facilities and the physicians and other health pro-
fessionals who work in them are under greater budgetary pressure than ever. For
example, the Balanced Budget Act of 1997 reduced payments to so-called TEFRA
hospitals (i.e., those hospitalsincluding psychiatric hospitalsthat are exempt
from the Prospective Payment System) by $5 billion.
So disadvantageous was this reduction that representatives of the psychiatric hos-
pital industry have decided to pursue PPS coverage. Likewise, payments to psychia-
trists and other health staff are constantly being squeezed by insurers, whether
Medicare or private.
Bluntly, psychiatrists and other health professionals and the facilities in which
we work are being asked to do more than ever for patients who are more acutely
ill than ever before with less resources. It is particularly disturbing to APA that dis-
cussion of resource commitment has, thus far, been entirely absent from the public
discourse.
THERE IS MORE AGREEMENT THAN DISAGREEMENT BETWEEN PSYCHIATRISTS AND
PATIENT ADVOCATES ON THE APPROPRIATE USE OF SECLUSION AND RESTRAINT
APA has a long-standing record of involvement with the development of general

guidelines and principles for the use of seclusion and restraint. For example, the
Report of the Task Force on Seclusion and Restraint (1984, amended 1992) provides
a very thorough overview of the practices in seclusion and restraint as they are used
in the treatment and management of violent and disruptive behaviors in the treat-
ment setting. The report also reviewed alternatives to the use of physical controls,
and it includes a very helpful discussion of indications, contraindications, and emer-
gency use of seclusion and restraint. We are attaching a copy of the Task Force Re-
port as a submission for the record.
In response to APAs concern about the patient care implications of the Courant
series, APA Medical Director Steven M. Mirin, M.D. directed that APA convene a
panel of experts first to develop a statement of general principles on seclusion and
restraint and, second, to develop clinical best practices standards.
The Joint Statement of General Principles on Seclusion and Restraint by the
American Psychiatric Association and the National Association of Psychiatric Health
Systems is also attached to this written testimony. We must note for the record that
the Joint Statement is to be viewed at the present time as a work in progress,
having not yet been formally reviewed and approved by the governing bodies of our
two associations.
We believe a careful review of these documents shows that there is more agree-
ment than disagreement on general principles governing the use of seclusion and
restraint between physicians and most patient advocates.
Here is a brief summary of the key points of our General Principles.
Seclusion and restraint are interventions that carry a degree of risk. They may
be used where, in the clinical judgement of medical staff, less restrictive inter-
ventions are inadequate.
Seclusion and restraint may be indicated (a) to prevent harm to the patient or
other persons including other patients, family members, and staff, and (b) to en-
sure a safe treatment environment.
A physician should write seclusion and restraint orders.
The physician should examine the patient and ensure appropriate monitoring
and care throughout the episode.
Staff should be thoroughly trained and have demonstrated competence in the
application of safe and effective techniques for implementing seclusion and re-
straint.
Patients should be removed from seclusion or restraint when, in the physicians
judgement, the patient no longer poses a threat to himself/herself, other pa-
tients, family members, or staff.
43
Use of seclusion and restraint should be minimized to the extent that is con-
sistent with safe and effective psychiatric care and the specific clinical needs of
the patient. Likewise, staff should be trained in the use of alternative interven-
tions that may reduce the need for seclusion and restraint. Facilities should en-
gage in a continuous quality improvement program that seeks to minimize the
use of seclusion and restraint consistent with good standards of clinical practice
and the needs of individual patients.
Death and serious injury from interventions involving seclusion and restraint
must be reviewed internally. In addition to internal review, external review by,
or subject to, an accrediting organization may also be required, with appropriate
legal and confidentiality protections.
THE CURRENT JCAHO PROCESS IS EDUCATIVE AND OFFERS A USEFUL MODEL FOR
CONGRESS
Let us now turn to a brief review of the JCAHO process. As you know, the stand-
ards for seclusion and restraint were significantly modified approximately 24
months ago. These modifications are consistent with and support the key points in
our statement of general principles. Before additional changes are made, it is our
judgement that the effect of the new standards on practice should be assessed.
The sentinel event policy and procedures is discussed in detail in the JCAHO
Special Report on Sentinel Events published in the Perspectives of November/De-
cember, 1998. Under standards set by the JCAHO and effective in January, 1999,
and laid out in the Accreditation Manual, a sentinel event is an unexpected oc-
currence involving death or serious physical or psychological injury, or the risk
thereof. Serious injury is defined to specifically include loss of limb or function.
It is useful to think of these as catastrophic events involving death or severe perma-
nent injury.
Sentinel events are divided into two basic categories: reviewable and non-review-
able. Reviewable events include those that have resulted in death or major perma-
nent loss of function, not related to the natural course of the patients illness or un-
derlying condition, and a series of specifically iterated events including suicide,
rape, and surgery on the wrong patient or body part. Major permanent loss of func-
tion is defined as sensory, motor, physiologic, or intellectual impairment . . . re-
quiring continued treatment or life-style change.
JCAHO-accredited facilities are encouraged to report reviewable sentinel events
voluntarily as they occur. Facilities are required to prepare a root cause analysis
and action plan and to submit both to JCAHO. Sentinel events reported to JCAHO
are included in the Joint Commissions Sentinel Event Database. Information cov-
ered includes sentinel event data, root cause data, and risk reduction data; non-
identifiable aggregate data are released.
The core, then, of the current JCAHO process is, in the words of the Commission,
to increase the general knowledge about sentinel events, their causes, and strate-
gies for prevention. As a practical matter, this aspect of JCAHO activities is edu-
cative. That is a critical component of efforts to minimize the general use of seclu-
sion and restraint and to eliminate deaths caused by seclusion and restraint.
As you know, hospital staff will typically hold after-the-fact debriefings when pa-
tients are restrained or secluded, and certainly when death is caused by seclusion
or restraint.
Any change in these standards must be carefully weighed against the impact it
will have on reporting of sentinel events and on its consequences for the best pos-
sible patient care.
We acknowledge and are sensitive to these concerns, and we also believe there
may be complex issues related to liability and discovery that the Congress and the
Joint Commission must also consider if they decide to change the standards for re-
porting of sentinel events involving seclusion and restraint.
THE JCAHO PROCESS CAN BE STRENGTHENED
Nevertheless, APA supports the strengthening of current sentinel event policy to

require the reporting of deaths caused by seclusion or restraint, as well as applica-
tion of the strengthened policy to serious injuries that meet the JCAHO definitions.
We stress here that we speak strictly for psychiatry, and not for the purposes of
our Joint Statement of General Principles. It follows that any shift in policy must
also carefully consider the information that may be required to be reported, espe-
cially in light of the need for confidentiality of data included in the reports. Even
greater care must also be taken to preserve the confidentiality of records if Congress
considers directing the JCAHO to amend its disclosure policy to report information
to other bodies.
44
SURVEYOR TRAINING AND EDUCATION ARE CRITICAL COMPONENTS OF EFFECTIVE
OVERSIGHT
Another area of potentially useful discussion is surveyor training. We believe that

the new survey process that requires the surveyor to interview patients in restraint
or seclusion, as well as the nursing and other staff responsible for their day-to-day
care, is a marked improvement. This hands on surveying process gives a better
picture of actual restraint issues than interviewing senior medical staff or simply
reviewing records.
We also emphasize the critical need for the surveyors to determine a facilitys
compliance with the standards requiring staff training. The literature clearly indi-
cates a correlation between staff training and a reduction in the use of seclusion
and restraint.
CURRENT FEDERAL LEGISLATION TO RESTRICT THE USE OF SECLUSION AND RESTRAINT
IS FRAUGHT WITH PROBLEMS
As you know, in addition to current JCAHO activities, legislation has been intro-
duced in the House and Senate to require reporting and review of deaths and inju-
ries of psychiatric patients.
It is not our purpose to review the bills in this testimony, although we would be
pleased to provide a detailed analysis for your review. We note, however, that there
are serious technical problems with all of the bills, including the following:
Inappropriate restrictions on the use of seclusion and restraint (i.e., for the safe-
ty of patients only, not for staff or others; no consideration of the treatment en-
vironment);
Potentially problematic external (beyond JCAHO) data disclosure with inad-
equate confidentiality protections;
Duplicative and adversarial involvement of the protection and advocacy systems
in reviewing and investigating deaths and serious injuries of psychiatric pa-
tients;
Imprecise definitions; and,
Failure to provide resources to meet the requirements established by the bills.
As clinicians, we believe that the ultimate responsibility for the decision to se-
clude or restrain the individual psychiatric patient must rest with the treating psy-
chiatrist. Well-intentioned law and regulation are at best a crude instrument that
cannot be a substitute for individual clinical expertise and judgement in which the
treating physician and the rest of the staff work as a team to make informed deci-
sions about optimum treatment for the individual patients in their care.
The fact remains that we are treating sicker patients in shorter time and in more
acute stages of their illness. This population is one in whichregardless of what one
may feel about restraints or seclusionwe simply cannot allow our distaste for the
intervention to take the place of clinical judgement and the safety of patients, staff,
and others.
APA STRONGLY SUPPORTS RESEARCH ON THE USE OF SECLUSION AND RESTRAINT AS AN
INTEGRAL PART OF ENSURING THE SAFE AND EFFECTIVE USE OF THESE INTERVENTIONS
We must be careful not to vest unexamined anecdotal information about restraint

elimination with the status of best practice when we truly do not know if that is
the case, or whether such practice is applicable to all patient populations in all
treatment settings. The APA strongly supports the need for more research on these
issues.
ANY SOLUTION TO THE CURRENT PROBLEMS WITH SECLUSION AND RESTRAINT MUST
INCLUDE THE COMMITMENT OF RESOURCES FOR STAFFING AND STAFF TRAINING
Finally, we believe that the current JCAHO emphasis on education offers useful
lessons to Congress about staffing and patient care. We absolutely agree that staff
must be trained in the appropriate and safe use of seclusion and restraint and that
competency should be regularly demonstrated. Staffing levels are also a vital issue.
We underscore, therefore, our continuing concern about legislative or regulatory
efforts that will materially increase the costs of care without concomitantly pro-
viding the resources to deliver such care. This is a major failing of each of the three
bills now pending in the Congress and should be a matter of concern to the Sub-
committee as it considers changes to current standards on restraint in behavioral
health care and on sentinel event policies.
Thank you for this opportunity to submit a statement for the record. It is our hope
that the Congressional interest in this vital patient care issue will provide for a
thoughtful review of the clinical issues associated with the use of restraint and se-
45
clusion and will lead to changes that truly ensure the provision of all medically nec-
essary treatment to psychiatric patients in an environment that is safe and humane
for patients and staff. To achieve this balance it is vital that psychiatrists be al-
lowed to participate in these discussions.
PREPARED JOINT STATEMENT OF GENERAL PRINCIPLES ON SECLUSION AND RESTRAINT

BY THE AMERICAN PSYCHIATRIC ASSOCIATION AND THE NATIONAL ASSOCIATION OF
PSYCHIATRIC HEALTH SYSTEMS
This is a statement of general principles on the use of seclusion and restraint in
psychiatric treatment facilities and in psychiatric units of general hospitals. Seclu-
sion is defined for this statement as locked door seclusion. Restraint is defined
for this statement as physical or mechanical restraint. Serious injury is used as
defined by JCAHO as of April 1999.
GENERAL PRINCIPLES
1. Our general goal is to ensure the provision of medically necessary psychiatric

treatment in an environment that is safe for patients and staff.
2. Seclusion and restraint are interventions that carry a degree of risk. They may
be used when, in the clinical judgement of medical staff, less restrictive interven-
tions are inadequate or are not appropriate, and when the risks of these interven-
tions are outweighed by the risks associated with all other alternatives.
3. Psychiatric treatment facilities and psychiatric units of general hospitals should
have established procedures for the use of seclusion and restraint that conform to
federal, state, or local regulations and standards of practice.
USE OF SECLUSION AND RESTRAINT
4. Seclusion and Restraint may be indicated: a. To prevent harm to the patient

or other persons, including other patients, family members and staff, when other
interventions are not effective or appropriate. b. To ensure a safe treatment environ-
ment when other interventions are not effective or appropriate.
5. Use of seclusion and restraint is a matter of clinical judgement that should in-
clude a thorough understanding of the clinical needs of the individual patient and
the context in which the use of seclusion or restraint is being considered.
6. Special care should be taken in assessing the clinical need for the use of re-
straint in special populations. Examples of special populations are children and ado-
lescents, the elderly, and the developmentally disabled.
PREVENTING THE NEED FOR SECLUSION AND RESTRAINT
7. The use of seclusion and restraint should be minimized to the extent that is
consistent with safe and effective psychiatric care and the specific clinical needs of
individual patients.
8. The provision of optimal psychiatric treatment, including appropriate use of
psychosocial and pharmaco-therapeutic interventions, is an important component of
a strategy to reduce the use of seclusion and restraint.
9. Another component of optimal psychiatric care is staff education and training.
Treatment facilities must have appropriate numbers of trained staff who are famil-
iar with the care of the specific patient population in the unit or facility.
10. Staff should be trained in the use of alternative interventions that may reduce
the need for the use of seclusion and restraint.
ORDERING AND IMPLEMENTING SECLUSION AND RESTRAINT
11. Seclusion and restraint are medical interventions that require a physicians
order.
12. The physician should examine the patient and ensure appropriate monitoring
and care of the patient throughout the episode.
13. Staff should be thoroughly trained and have demonstrated competence in the
application of safe and effective techniques for implementing seclusion and restraint
for the patient populations under their care. The techniques used should be ap-
proved by the medical staff.
14. Restraint should be applied with sufficient numbers of staff to ensure safety
of the patient and staff.
15. Patients in seclusion or restraint should be carefully monitored and observed
at intervals frequent enough to ensure their continued safety and the provision of
humane care.
46
16. The decision to continue seclusion or restraint should not be viewed as rou-
tine. Patients should be removed from seclusion or restraint when, in the physi-
cians judgement, the patient no longer poses a threat to himself/herself, other pa-
tients, or staff.
17. The use of seclusion and restraint may be traumatic for some patients. The
treatment team should consider post-intervention counseling whenever clinically in-
dicated.
TREATMENT PLAN REVIEW
18. A staff debriefing should follow each episode of seclusion or restraint. The de-
briefing should include an assessment of the factors leading to the use of seclusion
or restraint, steps to reduce the potential future need for the seclusion or restraint
of the patient, and the clinical impact of the intervention on the patient.
19. Use of seclusion and restraint, particularly when a pattern exists with an indi-
vidual patient, should prompt a review of the patients treatment plan.
20. Psychiatric treatment facilities and psychiatric units of general hospitals
should engage in a continuous quality improvement process that seeks to minimize
the use of seclusion and restraint consistent with good standards of clinical practice
and the needs of individual patients.
INTERNAL AND EXTERNAL OVERSIGHT
21. Quality assurance measures for seclusion and restraint should provide for the
appropriate involvement of family members or other public parties. These measures
must protect patient confidentiality and the clinical integrity of the treatment pro-
gram.
22. The decision to order seclusion or restraint requires the clinical judgement of
the treating physician, therefore policies governing seclusion and restraint are best
dealt with through flexible and easily amendable mechanisms such as hospital poli-
cies and procedures and administrative regulations.
23. Each psychiatric treatment facility or psychiatric unit of a general hospital
should have, in place, a system to review the frequency and use of seclusion and
restraint by each of its clinical units or groups with the intent of sharing best prac-
tices across units and facilities.
24. Death or serious injury resulting from interventions involving seclusion and
restraint must be reviewed internally. In addition to internal review, external re-
view by or subject to an accrediting organization may also be required, with appro-
priate legal and confidentiality protections.
[CLERKS NOTE.The Report of the Task Force on Seclusion and Restraint does
not appear in the hearing record but is available for review in the subcommittee
files.]

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S. HRG.

DEATHS FROM RESTRAINTS IN

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SUBCOMMITTEE ON DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND

MATERIAL SUBMITTED SUBSEQUENT TO CONCLUSION OF HEARING

TUESDAY, APRIL 13, 1999

OPENING STATEMENT OF SENATOR SPECTER

Senator SPECTER. We come to order for this hearing of the Ap-

Senator LIEBERMAN. Mr. Chairman, I want to thank you for hold-

In many ways, it was a trip back into medieval times, to a world

so that the cause of death or injury can be analyzed, preventive

I personally, and those of us in Connecticut and around the coun-

SUMMARY STATEMENT OF SENATOR DODD

Senator SPECTER. Senator Dodd.

fore you today on an issue, as Senator Lieberman has pointed out,

health. It is just an amazing statistic, but it happens to be the

Thank you very much.

REMARKS OF SENATOR TOM HARKIN

Senator SPECTER. Before calling on the ranking member, may I

that only three states have licensing and standard requirements,

erings were finally removed. CPR was unsuccessful, and Tristan

Today I urge the members of the 106th Congress to stand up and

step to making the United States a leader in the human rights

family member with severe and persistent mental illness. I am a

Therapeutic interventions should promote, maintain, or restore health or at least

Based on my experience as a practitioner, hospital accreditation and inspection

Despite much progress in psychiatry and an insistence that psychiatric illness is

As I mentioned, we must move away from institution toward

But if mandatory reporting of restraint-related deaths is a neces-

We support and welcome the opportunity to bring together the

Restraints oversight also lends itself to preventive monitoring as a part of the

Public accountability through public reporting of restraint-related deaths provides

There is another type of information-sharing that must be an essential part of any

STATEMENT OF THOMAS HARMON, EXECUTIVE SECRETARY, MEDICAL

requiring the reporting of all mental hygiene consumer deaths to

in February issued an alert to all hospitals across the state to ter-

Realizing the benefits of independent investigations requires that the inves-

Dr. MOHR. I think there is two parts to your question. Number

as facilitating the patients regaining their own self-control while

PREPARED STATEMENT OF THE AMERICAN PSYCHIATRIC ASSOCIATION

APA has a long-standing record of involvement with the development of general

Nevertheless, APA supports the strengthening of current sentinel event policy to

Another area of potentially useful discussion is surveyor training. We believe that

We must be careful not to vest unexamined anecdotal information about restraint

PREPARED JOINT STATEMENT OF GENERAL PRINCIPLES ON SECLUSION AND RESTRAINT

1. Our general goal is to ensure the provision of medically necessary psychiatric

4. Seclusion and Restraint may be indicated: a. To prevent harm to the patient

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