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Mold, Benadryl, and antipsychotic drugs: New report raises alarms about a state mental facility

Potent drug cocktails replace physical restraints at the medium-security facility for people with mental illness.

In this 2017 photo, Razor wire surrounds the Bridgewater State Hospital grounds.JohnTlumacki

It was to have been a “culture change” for Bridgewater State Hospital, Governor Charlie Baker promised back in 2016.

The medium-security facility for men suffering from mental illness who have been ordered incarcerated, civilly committed, or are being held pending trial, had been the subject of one expose after another, dating back to its starring role in the 1967 documentary “Titicut Follies,” and right through a 2014 class action lawsuit over conditions and use of restraints and seclusion.

But in 2017, while Bridgewater remained under the terms of that legal settlement, the Baker administration swapped out correction officers (who now only patrol the perimeter) for a private company that would essentially run the facility, providing security and clinical services. A host of glowing media reports followed, such as this one from the Globe:


“Five months in, the results are remarkable, beyond the imagining of mental health advocates. Since Correct Care Recovery Solutions took over management of the facility, the staff has cut the seclusion of patients by 99 percent and the practice of strapping them down by their wrists and ankles by 98 percent.”

In the intervening years, Correct Care became Wellpath, a national behemoth in the correctional health care industry, inmates became “persons served,” cells became “rooms,” and a gazebo was built in the outdoor recreation area.

As recently as last month, when Baker delivered his State of the Commonwealth address, he credited his administration for having “brought care and compassion to Bridgewater State Hospital after decades of national embarrassment.”

But a report issued last week by the Disability Law Center, which has a role in monitoring Bridgewater as part of the settlement of that 2014 lawsuit, paints a far less rosy picture of life today at the facility. The report describes a facility whose buildings are plagued with “harmful levels of mold growth” and where clinical practices include “illegal chemical and physical restraint and seclusion practices” and “a pervasive culture of punishment and intimidation.”


The use of physical restraints that led to that 2014 lawsuit has largely given way to what the Disability Law Center considers the too frequent use of injections of Benadryl (to induce drowsiness), Ativan (also used to treat anxiety and insomnia), and Haldol (an antipsychotic), often in combination, or Benadryl and the antipsychotic Zyprexa, and often administered by staff “using a manual hold.”

“It’s not just that it appears that they’ve traded using excessive seclusion and physical restraint for chemical restraint, they have also decided to use their own definition of chemical restraint so that they don’t have to report it [to the commissioner of the Department of Correction],” said Tatum Pritchard, director of litigation and interim executive director of the Law Center.

The report found what it called a “staggering” 370 instances of “emergency treatment orders” between June 26, 2021, and Nov. 25, 2021, involving those potent drug cocktails. This in a facility that houses about 225 men.

The report found “nursing notes, restraint and seclusion orders, and clinical records demonstrate” that such drugs administered on a supposedly emergency basis “were widely used to control behaviors that do not justify chemical restraint, i.e., where no imminent threat of serious harm to self or others existed.”

They cited one instance where a man was loudly banging on his door demanding food, another was just described as being “uncooperative and agitated.”


Some of the men being held at Bridgewater reported to Law Center investigators that at times “therapeutic safety technicians” entered their rooms dressed in “black tactical gear and helmets” and carrying shields in order to administer the medications.

Yes, it seems the short-lived “culture change” today looks more like new names for the same old way of doing things.

In fact, Pritchard noted that most of those responsible for the 2017 turnaround who were reported on so glowingly are “long gone.”

The Disability Law Center report faults Wellpath for “systemic deficiencies” in reporting its use of chemical restraints and seclusion, but noted that the state Department of Correction “bears absolute responsibility for ensuring that its contractor is meeting both contractual and legal requirements.”

The department, according to a spokesperson, is still studying the report, which was turned over to them on Jan. 31.

Among the many recommendations made by the Law Center report is that state officials call on the Department of Mental Health or an “external party” to investigate the use of medications as chemical restraints and the shoddy record-keeping that has aided and abetted it.

State lawmakers, who have tasked the Disability Law Center with investigating the management of Bridgewater and provided the funds to do it, could certainly follow up — ordering correctional and Wellpath officials to give a public accounting of how they intend to fix the issues raised in the report, including the issues of a deteriorating physical plant and the use of chemical restraints.


Outsourcing the running of a mental health facility to a private company seemed for a time the answer to decades of problems. And while that decision improved conditions at Bridgewater in some respects, it’s clearly no panacea. Now the move appears to have also muddied the lines of responsibility, while those confined inside the barbed wire fencing continue to pay the price for that bureaucratic muddle.

The case for outside oversight — suggested repeatedly by the Disability Law Center over the years — remains undeniable. Lawmakers should insist on nothing less.

Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.