MIDDLETOWN, Conn. — Clinicians treating some of this state’s most dangerous mental health patients faced a crisis in 2002, when a patient cuffed hand and foot to the hospital floor choked on his tongue anddied of a heart attack. His family then sued, and the Justice Department began investigating whether the Whiting Forensic Division was violating patients’ rights by improperly isolating them and strapping them down.
So Whiting clinicians decided to join a growing movement to sharply limit how often agitated mental health patients are placed in seclusion rooms or physically restrained. They began rewarding good behavior so that patients were less likely to become violent in the first place, and trained staff in how to defuse confrontations.
The results were stunning: The use of seclusion and restraints at Whiting, Connecticut’s mental health center for patients involved in the criminal justice system, has dropped by more than 88 percent since 2004, according to data analyzed by the Globe.
But the cultural change that swept Whiting and many other psychiatric facilities never reached Bridgewater State Hospital in Massachusetts, now under intense scrutiny for its practices, after the death of a young mental health patient while he was being strapped to a bed in Bridgewater’s Intensive Treatment Unit.
Even as Whiting and other mental health centers were reducing their use of seclusion and restraints, Bridgewater relied on them even more. Over the last decade, use of those harsh methods increased by 16 percent at Bridgewater, and the rate of use continued to rise rapidly even after the 2009 death in restraints of 23-year-old Joshua K. Messier, a Globe analysis shows. The Globe reported in February that none of the guards in Messier’s cell the night he died had been disciplined even though the medical examiner ruled his death was a homicide.
In the wake of the Globe report about Messier’s death, Department of Correction officials say they’ve begun making significant strides in reducing the use of seclusion and restraints, cutting the use of restraints by 98 percent by the end of May, as advocates and outside consultants scrutinized the hospital’s practices.
“I think people are trying, without compromising the safety of patients or staff, to be very measured when placing someone in seclusion or restraints,” Sandra M. McCroom, an undersecretary of public safety, said in a Globe interview Friday.
‘The message I wanted to send was, we’re all fighting this battle together . . . [and] I’m watching.’
But the longer view of Bridgewater practices remains grim.
Hospital data for the year 2013 show that Bridgewater patients were 200 times more likely to be placed in isolation or restraints than patients at Whiting, even though the facilities treat similar patients — potentially violent mentally ill people who in most cases have been charged with crimes. In 2013, Whiting clinicians isolated or restrained patients at a rate of 6.8 hours per 1,000 patient days, compared with 1,409.8 hours per 1,000 patient days at Bridgewater.
Data from two other mental health facilities that treat patients similar to Bridgewater’s likewise suggest that Bridgewater has been a national outlier when it comes to relying on seclusion and restraints to control patients. Bridgewater used the harsh tactics at least five times more than similar hospitals in New York and Maryland.
Outside observers say the yawning gap may reflect the corrections mind-set of officials at Bridgewater, one of the very few forensic hospitals nationwide that is run by a department of correction instead of a department of mental health.
“The prison mentality controls,” said James R. Pingeon, an attorney with the not-for-profit group Prisoners’ Legal Services.
Low staffing levels and funding may also have been to blame, problems that have hobbled Bridgewater’s effectiveness for years. A blue ribbon panel warned in 2005 that Bridgewater lacked the resources “to provide ongoing best practice treatment,” and today Connecticut spends more than three times as much per patient at Whiting as Massachusetts spends at Bridgewater.
Whatever the reasons for the high rate of seclusion and restraints at Bridgewater, Roderick MacLeish Jr., an attorney who recently filed a class action lawsuit on behalf of patients at the facility, said secluding and restraining severely mentally ill people can amount to “torture.”
“Secluding even an ordinary person for thousands of hours is torture, but isolating someone who is severely mentally ill with nothing but the voices in his head for prolonged periods of time can be catastrophic,” he said.
Less than a week after the Globe’s report on Messier’s death, Governor Deval Patrick announced a firm commitment to reduce the use of a seclusion and restraints, and pledged to provide a complete accounting of the official response to the Messier tragedy.
“Unless it can be said with certainty that the inmate poses a serious and immediate physical danger to himself or his fellow inmates, he should not be tied down, limb-by-limb, in the 21st century here in Massachusetts,” he said.
Public Safety Secretary Andrea Cabral, who oversees the Department of Correction, disciplined six department officials in March for the roles they played in Messier’s death and its aftermath, and last month named a nationally recognized expert to train Bridgewater clinicians and prison guards in alternative techniques for controlling potentially violent patients.
Three months later, state officials say that reform efforts are paying off. McCroom said that Bridgewater has cut its use of restraints by 98 percent in May compared with January, while reducing its reliance on seclusion by more than 60 percent.
McCroom said clinicians now are carefully reviewing each case before patients are restrained or secluded, and the staff is heeding Commissioner Luis S. Spencer’s call to create a “healing environment” at the facility.
But advocates for mental health patients at Bridgewater question the administration’s commitment to change. They point to the track record of obduracy by high-level Department of Correction officials who insisted for years there was no misconduct in the Messier case — until a lawsuit filed by Messier’s family and the Globe story recounting details of his death forced the administration to act.
Even now, advocates point out that Massachusetts officials don’t want to compare Bridgewater to facilities in other states that have better records on the use of seclusion and restraints.
McCroom said comparisons to other forensic hospitals are inappropriate in part because many spend more per patient and have the option of transferring the most violent patients to other facilities, while Bridgewater doesn’t.
“It is truly like comparing apples to oranges,” she said.
Start of nationwide effort
The national movement to curtail and even eliminate the use of seclusion and restraints on mental health patients followed an alarming 1998 series in the Hartford Courant, which found that 142 people, most of them young children or teenagers, died over a period of 10 years in psychiatric hospitals and other facilities across the nation while being restrained or secluded.
Since then, mental health professionals have developed strategies for reducing the use of those measures that have been widely adopted at psychiatric hospitals. Even at forensic hospitals that treat the small proportion of the severely mentally ill who have been convicted of violent crimes or charged with committing them, administrators have embraced the change.
“Seclusion and restraints can traumatize or re-traumatize patients and they can lead to injuries of patients and staff,” said David S. Helsel, a psychiatrist and the chief executive officer at the Clifton T. Perkins Hospital Center in Maryland. “There are a number of compelling reasons to not only reduce but to eliminate seclusion and restraints.”
At Whiting, located on the grounds of Connecticut Valley Hospital, officials developed a program that included lavish praise of positive patient behavior, group discussions focused on sports and other topics popular with patients, and patient involvement in formulating a list of “intolerable behaviors.”
Charles Dike, a Yale University-trained psychiatrist and the director of the Whiting Forensic Division, said that when he helped launch the program, he also decided to get personally involved with each decision over whether to place a patient in seclusion or restraints.
“The message I wanted to send was, we’re all fighting this battle together,” he recalled. “The other message I wanted to send was, I’m watching.”
Meanwhile, at Perkins Hospital in Maryland, Helsel said he would like to eliminate the use of seclusion and restraints within five years, using techniques he employed successfully while director of another psychiatric hospital in Maryland. For instance, a patient’s best coping mechanisms are written on flash cards that clinicians will hold up when a patient starts to become agitated.
“If you can manage the person’s anger and violence using appropriate techniques for just long enough for them to calm down, you can often avoid using restraints entirely,” he said.
Like Dike, Helsel said the direct participation of top hospital administrators in case-by-case decisions about whether to use seclusion or restraints is key, to model behavior for staffers and “put our money where our mouth is.”
Yet managers at the Department of Correction and at Bridgewater have been slow to tap into the movement to handle potentially violent patients more humanely. Commissioner Spencer, for instance, has said he does not review staff decisions to place patients in seclusion or restraints, leaving that to medical staff members, even though state law requires him to do so.
And Massachusetts has actually cut its mental health care budget by $100 million, or more than 12 percent, since 2001, according to the Massachusetts Budget and Policy Center, a nonprofit, nonpartisan group that adjusted the figure for inflation.
Specialized ward closed
If anything, Massachusetts officials made the problem for the acutely mentally ill more precarious by closing a specialized ward at Taunton State Hospital for severely mentally ill patients who were violent, or potentially violent, in 2003, hoping to save $2.2 million a year.
Bruce Swartz, director of the 13-bed Difficult to Manage Unit when it was located in Medfield for most of the 1990s, said he resigned after the budget for the unit was threatened, and later cringed when he read comments from state officials saying it was no longer needed.
“I remember reading that and saying, ‘Wow, they’ll say anything to move their agenda forward,’ ” Swartz recalled, referring to the department’s budget-cutting goals. “I knew it was baloney at the time, and 10 years later that seems to have been the case.”
MacLeish, the attorney whose 1987 lawsuit led to the creation of the Difficult to Manage Unit, said patients like those who once were sent there now are committed to Bridgewater, consigning them to the life of prisoners living behind barbed wire fencing, even though many have not been convicted of a crime.
At Bridgewater, patients are most frequently secluded or restrained in one of more than a dozen cells in the Intensive Treatment Unit. Messier died in one of these cells as guards preparing to strap his wrists and ankles to a small bed folded him over at the waist and pushed down on his back, causing him to suffer a heart attack — an incident captured on prison video.
Pingeon, the Prisoners’ Legal Services lawyer, suggested the existence of the ITU may be fueling Bridgewater’s high rate of seclusion and restraint.
“It may be that it’s hard to resist putting someone in the unit when it’s there,” he said.
In addition, two lawsuits recently filed on behalf of Bridgewater patients by MacLeish allege clinicians have been putting patients into seclusion and restraints for minor incidents that do not meet the definition of a safety “emergency” described in state law — and holding them there for extended periods of time.
The lawsuits allege that Peter Minich, a 31-year-old Brookline man diagnosed with paranoid schizophrenia and never convicted of a crime, was held in seclusion for more than 6,300 hours, and in four-point restraints for more than 800 hours, beginning in January 2013.
The lawsuits say clinicians confined Minich to seclusion or restraints in Bridgewater’s ITU for behavior that included bothering another patient, being assaulted by another patient, and experiencing auditory hallucinations, a common feature of his mental illness.
But the lawsuits also underscore the potential for reducing the use of seclusion and restraints at the facility. After negotiations with MacLeish, Bridgewater officials agreed to develop a treatment plan designed to keep Minich out of seclusion and restraints that has met with success.
“As a result of the filing of the lawsuit,” MacLeish wrote in a legal brief, “a Bridgewater patient who was spending 70 percent of his time locked alone in a seclusion room has since been seclusion free for five weeks.”
There are other signs of change, too. Last month , Patrick made his first visit to Bridgewater in his nearly eight years as governor, telling top staffers and advocates for the mentally ill that he wanted a report on short-, medium-, and long-term solutions to the crisis at Bridgewater.
Meanwhile, clinicians and guards at Bridgewater spent much of last week in training sessions with an outside consultant, Joan Gillece, a nationally recognized expert on reducing the use of seclusion and restraints.
Still, advocates fear that once Patrick leaves office the controversy over the use of seclusion and restraints at the medium-security prison will subside without substantive change, just as it has after past reform efforts. Almost 20 years ago, an outside consultant warned that Bridgewater officials make “treatment a secondary consideration,” something advocates say is still true today.
“As long as [the Department of Correction] is in charge of Bridgewater and runs it with that prison mentality, any reforms that may come from all this attention will be superficial and will fade away as soon as the spotlight turns elsewhere,” said Pingeon.
Any fundamental change at Bridgewater is likely to require significant spending, whether the state decides to re-open a facility like the old Difficult to Manage Unit, or transfers management of Bridgewater to the Department of Mental Health.
Housing a mental health patient at Bridgewater costs about $145,000 a year, according to the Department of Correction.
By contrast, housing a patient in a Department of Mental Health facility costs an average of $400,000, while the price tag for housing a patient at the Whiting Forensic Division in Connecticut runs to nearly $500,000.
But last month Public Safety Secretary Cabral suggested the Patrick administration is unlikely to commit significant additional funds to open a facility for acutely mentally ill patients with the potential for violence.
“It’s less about the facility and where people are held as long as the outcomes and the training are good,” she said. “That’s really what the goal is.”