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Change May Be Coming

Last winter, 16-year-old Tristan Sovern was admitted to a Charter psychiatric hospital in Charlotte, North Carolina, suffering from depression. A week into his stay, while being restrained, he was asphyxiated. In psychiatric care, a restraint is a serious procedure in which a patient is strapped by the wrists and ankles onto a bed. While trying to restrain him, the staff had covered his mouth with a towel, and then a sheet.

Officials investigated, and ended up charging one of the employees with involuntary manslaughter. Her trial began April 20.

Spurred by this case, dozens of other restraint-related deaths and injuries across the country, and reports of widespread abuse of the practice, Congress, mental health advocates, and industry groups are all looking for ways to reform the use of restraints.

In March, two restraint-related bills were introduced in Congress. Both would restrict when restraints could be used and require psychiatric institutions to report any deaths or serious injuries - whether related to restraints or not - to the federal government. There is now no federal requirement to report unexpected injuries or deaths (known in the psychiatric industry as "sentinel events"), and only 16 states require hospitals to report deaths.

"The facts certainly seem to warrant the conclusion that restraint and seclusion are cruelly overused in America's mental health institutions," says Sen. Joseph Lieberman (D-Conn.), who with his Connecticut colleague Sen. Christopher Dodd (D) co-sponsored the Senate bill. "They are used inhumanely. And too often they are used with fatal results."

Congresswoman Diana Degette (D-Colo.), along with Pete Stark (D-Cal.) and Rosa DeLauro (D-Conn.), proposed a similar bill in the House of Representatives. The bills are supported by the Clinton administration.

Mental health advocacy organizations, which have long been pushing for reform, are throwing their support behind the legislation. "I think it's absolutely time for this," says Joseph Rogers, executive director of the Mental Health Association of Southeastern Pennsylvania. Rogers, who testified at Senate hearings earlier this month about his own experiences with restraint, believes that most restraints are unnecessary. "Restraint rarely has to do with therapy," he says. "The reality is that people who are restrained could usually be dealt with in other ways."

Not everyone approves of the proposed changes. The American Psychiatric Association, which has 41,000 members, opposes the legislation, arguing that it is over-regulation. "Are you going to require a hospital to report a death every time there's a medication error?" says New Haven psychiatrist Charles Riordan, who co-wrote the APA's statement on the issue. "Are we going to report every time someone dies in a hospital as a result of error? How many more duplicative reports are we going to have?"

Several industry groups ar also examining restraint reform. Last week the nation's largest chain of psychiatric hospitals, Charter Behavioral Health Systems, announced a plan to sharply reduce use of restraints over the next three years. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an industry organization that evaluates psychiatric facilities all over the country -- and determines which hospitals are eligible for Medicare and Medicaid - recently held hearings on restraint around the country.

Some observers, though, express suspicion of these moves, saying that they are simply responses to the publicity about restraint abuses in psychiatric institutions. Charter is the subject of investigations by the U.S. Inspector's General office as well as CBS. JCAHO has been criticized for accrediting hospitals that misuse restraints.

"I hope they're more than public relations responses," says Curt Decker, executive director of the National Association of Protection and Advocacy Systems, a federally-funded non-profit agency that investigates complaints of abuse and neglect at mental health institutions. "My cynical side says 'a day late, a dollar short.' But I'll take the movement whenever it comes. The fact that it might have been motivated by all the negative press -- so be it."

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Written by David Kohn