Seclusion and restraint practice poses risks, prompts questions
September 23, 2010
(Note: This part three in a three part series. Part one highlights how the father of a mentally ill man fought for his son. Part two told of the man’s last hours. Noozhawk followed the ordeal of Rich Detty, a Santa Maria man whose son, Cliff, died while under restraints at a Santa Barbara County psychiatric health facility in April.)
A week after Cliff Detty’s death at Santa Barbara County’s Psychiatric Health Facility, a short obituary popped up online. Without going into detail, the article described a 46-year-old man who had died at a Santa Barbara hospital the night of April 29, 2010.
Diagnosed with paranoid schizophrenia, Detty had been transported to the psychiatric unit from the Marian Medical Center emergency room in Santa Maria.
“All persons with mental illness have a right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse or neglect,” according to the California Welfare & Institutions Code. Whether Detty’s case constitutes “excessive” restraint and isolation has yet to be determined. But it seems clear that after hours of screaming and struggling to be free from the restraints that held down his limbs and torso, Detty’s life was cut short.
When asked about PHF’s seclusion and restraint policies and whether they were up for review after Detty’s death, Ann Detrick, director of the county Department of Alcohol, Drug and Mental Health Services, had little to say.
“Our department has a responsibility to comply with all regulations and a commitment to continuously review our service-delivery practices to make improvements and assure the highest quality of care,” she told Noozhawk. Detrick has repeatedly declined to comment on Detty’s case.
Detty’s last hours at the Psychiatric Health Facility are hard to forget. But those who knew him throughout his life remember a sunnier image. A picture of Detty’s happier days involved a trip up Highway 101 to Santa Maria, and a visit to one of his favorite places, the city’s idyllic Waller Park.
It’s a place that Detty’s father, Rich, describes as one of his son’s favorite childhood hangouts, and where about 60 people showed up on a warm day in early June for his memorial.
Pictures of a happy young boy were taped to a piece of white cardboard on one of the park’s picnic tables, the images interspersed with words like “athlete” and “surfer” written in magic marker.
A picture of Detty at about 10 or so shows a proud boy holding up a half-dozen freshly caught fish. Another shows a smiling young man in his twenties with feathered hair and wearing a Hawaiian shirt. As people milled around talking and taking in the photos, another friend set down Detty’s surfboard next to the pictures.
Rich Detty graciously greeted guests, encouraging them to help themselves to the grilled chicken and tri-tip prepared for the cookout. One person at the memorial that day was Jeff Parker, a friend of Detty’s who worked formerly as a psychiatric technician at Atascadero State Hospital.
People get put in restraints when they’re deemed to be a threat to themselves or others, said Parker, who added that he had no idea what Detty had done to be judged dangerous enough to be placed in restraints.
Parker also takes issue with how Detty was monitored.
“You don’t leave someone alone,” he said. “You just don’t do that.”
The state Health and Safety Code states that patients in seclusion and restraint are to be kept under constant, face-to-face human observation. Parker goes even further and says an attendant should be within an arm’s length of the person restrained.
Although the medical records showed that Detty was dutifully checked on by staff every 15 minutes, the rest of the time he was observed by a closed-circuit audio and video system. Detrick maintains that this approach is allowed in the facility under federal regulations.
But the amount of monitoring does not appear to have been sufficient. According to a cardiologist Noozhawk consulted about the Detty case, for every minute the heart has stopped, the chance of survival decreases by 10 percent. If Detty died just after a 15-minute check, his fate was effectively sealed, the cardiologist said.
Paul Bragg, a childhood friend of Detty’s, was also at the memorial. The pair had grown up together, but Bragg said he’d seen something in Detty begin to change about seven or eight years ago. Toward the end of his life, many of Detty’s friends couldn’t tolerate his behavior. But Bragg was one of the few who stayed with him, and even recounted letting Detty use the bathroom in his house when he was living on the streets.
“Something wasn’t right, but he was always welcome in my house,” Bragg said.
He recalled the last time he spoke with Detty, about two weeks before his death.
“We had a beer together, a Fat Tire,” he said, tears streaming down his face. Even with his erratic behavior, Bragg chose to stay friends with Detty. He said he dreamed of buying a yacht that he would sail while Detty fished for the scores of fish he was known for bringing in.
“I always thought that would happen someday,” he said, a flood of new tears forming. “But it all started to fade away as the drugs started.”
Nearly everyone interviewed for this series said similar things about Detty, that he had been the life of the party in high school and beyond. “Happy go lucky” and “up for anything” were all used to describe him in his earlier life.
But after time passed, when his friends hadn’t seen him for five or 10 years, Detty would suddenly materialize, seemingly out of the blue. One woman said she had run into him at the grocery store while another had noticed him walking down the street.
Parker recalled walking through the lunch room at Atascadero State Hospital when he heard a voice from behind him call out his name. He turned and saw Detty sitting at a table; he had been
admitted to the mental hospital as a patient. But once he was there, Detty was gone again, back into the shadows to wrestle with his own demons. That transparent presence might have been put best when one friend spoke for everyone at the barbecue, his voice dropping into a low, sad timbre: “We’ve missed Cliff a long time.”
Detty’s story is laced with larger philosophical questions, but one is more specific: Is restraining a patient acceptable at all?
What mental health advocates and concerned county residents will do about Detty’s death remains to be seen. But models for change exist.
“In the past decade, there has been a change in the standard of care in the use of restraint and seclusion in mental health facilities nationwide and within the state,” according to Leslie Morrison, an expert on seclusion and restraint and director of the Disability Rights California investigations unit.
Morrison helped craft Health and Safety Code 1180, which created more safeguards for individuals in seclusion and restraint. She told Noozhawk that many facilities have reduced or eliminated these practices, minimizing risk.
“Yet, we continue to see deaths and serious injuries occurring during the use of restraint or seclusion in facilities that have not kept up with the change in practice standards,” she said.
Santa Barbara County’s 16-bed unit tends to keep patients in restraints almost three times as long as other similarly sized California facilities that submitted quarterly reports to the state Office of Patient Rights, according to OPR data.
Pennsylvania has all but eliminated seclusion and restraint from its state hospitals and has become a model nationwide for patient-centered mental health care. And success stories have happened within California, as well. Metropolitan State Hospital in Los Angeles greatly reduced staff injuries after reducing seclusion and restraint use among its nearly 700 patients.
Cynthia Lusch, clinical administrator for the hospital, said the staff started working on the problem in 2007 when employees noticed the childhood program had high levels of restraint.
“What we found was when you had a high prevalence of restraint, injuries were also high,” Lusch said.
By looking at ways to intervene that were less hands-on, Lusch said staff members were retrained in additional methods to control aggressive behavior besides seclusion and restraint or medication.
“We’re asking what kinds of things help and make the situation worse,” she explained. “Would listening to music help? We’re restructuring the environment instead of forcing them into it.”
Lusch said the hospital hasn’t done away with restraints altogether, but it has one of the fewest restraint episodes among state-operated hospitals.
“Many of our individuals have had very traumatic lives,” Lusch said. “The restraint episode itself could trigger a traumatic incident in their lives, reinforcing that, when you’re expecting them to get better.”
The change hasn’t happened overnight. Deciding on small steps, like not keeping sleeping patients in restraints, precipitated bigger culture shifts.
“Over time we noticed, ‘Oh, my gosh, we went a whole week without using restraints.’ Then it was a month,” she said.
“It has to be something that the leadership of the hospital sees and says it needs to be done,” she said. “If everybody’s not on board with it, it won’t work.”
The Substance Abuse and Mental Health Services Administration published a national action plan to reduce seclusion and restraint in 2003. Eliminating the use of seclusion and restraint takes an adequate number of staff, trained in how to de-escalate patients and use verbal crisis management.
“Staff are likely to treat their patients in the same way as they are treated by management,” the report said. “When staff are treated in a dictatorial, controlling manner, they treat their clients through extreme control and use of rules. But if staff are treated in a warm and caring way, they treat those they serve with compassion and care.”
And although Santa Barbara County is facing what seem like perpetual gouges to its budget from the state of California, reducing seclusion and restraint may not be a matter of funding.
“Numerous examples exist in which the use of restraint and seclusion has been reduced without major expenditures when facility administrators publicly commit to doing so,” according to From Restraint and Seclusion — A Management Guide written by Kevin Ann Huckshorn, a nurse and advocate for the reduction of seclusion and restraint. “Approaches that focus on ‘doing restraint and seclusion better’ leave a facility exposed to major risks.”
In addition to the ethical question of restraint, Detty’s case poses other questions. One posed earlier in Noozhawk’s series, asked what happens when an intervention is needed, and the person needing the intervention isn’t well enough to allow it?
Under current law, patients must present a danger to themselves or others, or be deemed gravely disabled to be taken in for emergency treatment involuntarily. In Detty’s case, his father repeatedly was turned away from mental health under these premises: Detty would have to come in on his own terms to get help. But another group says that law needs to change, and provides the blueprint for doing so. The Treatment Advocacy Center, an Arlington, Va., nonprofit organization focused on eliminating barriers to treatment of severe mental illnesses, says California counties can opt in to a provision called Laura’s Law that would help people exactly like Detty.
The law revolves around assisted outpatient treatment for people who are unable — or won’t — access mental health services voluntarily. Any adult with whom the person resides, as well as a set of other qualified people, can petition the local Superior Court for treatment for the person with mental illness. The county mental health director then conducts an investigation to determine whether the person qualifies, and if so, the person enters a six-month outpatient treatment program. The Treatment Advocacy Center says the money to pay for such treatment can come from state funds, such as the Mental Health Services Act, that ADMHS already receives.
“There are so many tragedies that just get swept under the carpet,” said Carla Jacobs, one of the founding board members of the Treatment Advocacy Center. The current laws on the books “basically discriminate against people with mental illnesses,” she said.
“There are so many times he could have been given help,” Jacobs said of Detty.
Two California counties — Los Angeles and Nevada — have already opted in on the law, and Los Angeles County has established a small pilot project with a hospital discharge plan. The assisted outpatient treatment approach relies on both a court order and an intensive community treatment plan. Without both, the plan is insufficient, Jacobs said.
“It’s really one of the first times accountability has been brought into the system,” said Jacobs, who added that, currently, there’s little follow-up with patients.
She says the plan would reduce hospital utilization, one of the most expensive forms of treatment. And the money would be used in such a way “where people actually get better,” she said.
But the plan can’t — and won’t — go forward unless county supervisors are behind it, according to Jacobs, and that implementing an assisted outpatient treatment plan requires “bureaucratic creativity and political will.”
Meanwhile, if anyone tries to call Rich Detty on his home phone, they’ll find his answering machine full of messages and switched off. He says he turned off the machine a few days after his son’s death because there are still five or six messages from him preserved there.
They’re just a few short messages of Cliff asking for help with his car. “But once I erase those messages, his voice is gone forever,” Rich Detty said. “Right now, I can’t do that.”
It’s been almost four months since Detty’s death, but Rich Detty still gets a sick feeling in his stomach when driving on Highway 101, past the PHF unit in the county complex at 315 Camino Del Remedio. He says he’d like to see the policies changed at the facility, but admits what happened to his son is something he may never come to terms with.
“My personal opinion is that it should have been handled different … because there was no reason for him to die,” he said.