Shannon's story

“I was an excited big sister when my brother Jeffery was brought home from the hospital. Growing up I taught him how to ride his bike, tie his shoes, and how to make it through the first day of school. He grew up to be an avid skateboarder and beachgoer, all the qualities of a true San Diegan. He was full of life and love even while struggling to manage a mental health challenge.

“Jeffery's death at the age of 25 during the spring of 2008 came as a devastating unexpected surprise to all of us. It never occurred to us that he would die, much less die in a hospital since we assumed he was safe there. We thought he would receive the care he needed in a safe place until he regained the upper hand with his illness. We were wrong.

“Our mom was standing in the hospital parking lot when Jeffery died. She had called our grandmother on her cell phone and they were both in tears, feeling helpless. They didn't yet know that Jeffery was dead. She had left the ward after a half-hour visit because the staff had taken him away, not because he was exhibiting dangerous behavior, but because he did what he usually did when he was distressed—he knelt down on his knees. This was a compulsive gesture that he had developed that was hard on his knees, but not life-threatening.

“Mom was visiting Jeffery when the incident began. It was almost time for the regularly scheduled cigarette break, so Jeffery excused himself to go have a smoke. He was three minutes early, and staff told him to go back and sit down. Jeffery began to kneel. He was offered Ativan, which he accepted (later they gave him two shots of Thorazine, on top of four other medications).

“Mom rubbed his back to soothe him, but soon several large staff came to take Jeffery away. She thought he was being taken to a quiet room so they could calm him and make him comfortable. Little did she know that Jeffery would be put in five-point restraints, belly down (even though he asked never to be placed on his stomach for fear of suffocation).

“Minutes after mom got home, the phone rang and she was told that my brother was dead. He died alone when no one was watching. The autopsy report indicated that he died of a heart attack brought on by being restrained and an overdose of medication. How could this happen in 2008, when we supposedly know how to help people like Jeffery recover? As you can imagine, our family had a million questions.

“It wasn't until after he passed away that we found out this hospital had used restraints on Jeffery three other times during his one-week stay with them. In one report we read that Jeffery asked the staff, ‘If I am good, will you release one of my ankles?’ We also found out that he asked not to be strapped down on his belly, but that is how he died.”

Questioning tradition

How could this tragedy have been avoided? What can we learn from Shannon's story that can keep this from happening ever again? Although we don't know all the details, here are a few questions that come to mind:

Was there a power struggle between Jeffery and the staff? At the root of this sort of incident often is a power struggle, with staff believing that their job is to enforce the rules no matter what and administer punishment when they are not followed. We recommend avoiding power struggles altogether. No one wins.

Were alternatives to restraints explored? Restraints often are staff's first line of defense, just because it always has been that way. Yet many other options could have been taken in this case. Jeffery could have been given some choices and flexibility around the smoking time. His mother could have been encouraged to continue to soothe him.

Was Jeffery being chemically restrained? In fact, if Jeffery's behavior was not harming himself or others, why was he restrained—physically or chemically?

How much more help could Jeffery's mom have been if she had been given the chance? She was willing to help and was doing what she knew usually worked for him by rubbing his back. The important contributions family members can make often are overlooked and negated. From what we know of this situation, she could have been instrumental in intervening and helped staff to avoid using restraints.

Does the hospital view using seclusion and restraints as a treatment failure? Is it committed to eliminating these practices, as other hospitals have done?

Were staff trained in deescalation, and were they encouraged to use it as a preferred approach? Were they trained in recovery practices, which can have a profound impact on self-defeating behavior?

In other venues would behaviors similar in intensity to seclusion and restraint activities be called “police brutality” or even “torture?”

We cannot talk about recovery without talking about efforts to eliminate seclusion and restraints. Bill has called such force the “elephant in the room” as the mental healthcare field tries to become more recovery-oriented.1 We conclude this plea for change by repeating two statements we have previously made:

“It is important to recognize that eliminating a tradition that is firmly ensconced in any culture is a challenging assignment. Seclusion and physical restraint have been practiced in behavioral health settings for centuries and have been assumed to be a necessary routine in the treatment process. We now know that these methods have serious detrimental side effects and that there are better ways that can actually promote personal growth and recovery when directed by leadership and practiced with committed action by staff. The use of seclusion and restraint can be eliminated when other beliefs and principles are practiced.”2

“I repeat my challenge to myself and to my colleagues. Let us commit to figuring out how to stop our mindless use of force. Let us use our best minds…to find ways to extricate our field from being society's purveyor of force. We need leaders to champion, develop, and demonstrate effective alternatives to force and then to permeate the field with these practices. We cannot and must not accept the use of force that pervades our field.”3