Saturday, January 28, 2012


SUMMARY: Forty-four states permit the use of assisted outpatient treatment (AOT), also called outpatient commitment. AOT is court-ordered treatment (including medication) for individuals who have a history of medication noncompliance, as a condition of their remaining in the community. Studies and data from states using AOT prove that it is effective in reducing the incidence and duration of hospitalization, homelessness, arrests and incarcerations, victimization, and violent episodes. AOT also increases treatment compliance and promotes long-term voluntary compliance, while reducing caregiver stress. The six states that do not have AOT are Connecticut, Maryland, Massachusetts, New Mexico, Nevada, and Tennessee.
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Assisted outpatient treatment (AOT) is court-ordered treatment (including medication) for individuals with severe mental illness who meet strict legal criteria, e.g., they have a history of medication noncompliance. Typically, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment.
Forty-four states permit the use of assisted outpatient treatment (AOT), also called outpatient commitment. The six states that do not have assisted outpatient treatment statutes are Connecticut, Maryland, Massachusetts, New Mexico, Nevada and Tennessee.  
A substantial body of research conducted in diverse jurisdictions over more than two decades establishes the effectiveness of assisted outpatient treatment in improving treatment outcomes for its target population. Specifically, the research demonstrates that AOT reduces the risks of hospitalization, arrest, incarceration, crime, victimization, and violence. AOT also increases treatment adherence and eases the strain placed on family members or other primary caregivers. Following are summaries of key findings. 


Several studies have clearly established the effectiveness of AOT in decreasing hospitalization.

Researchers in 2009 conducted an independent evaluation of New York’s court-ordered outpatient treatment law (“Kendra’s Law”) and documented a striking decline in the rate of hospitalization among participants. During a six-month study period, AOT recipients were hospitalized at less than half the rate they were hospitalized in the six months prior to receiving AOT (i.e., the hospitalization rate dropped from 74 percent to 36 percent). Among those admitted, hospital stays were shorter: average length of hospitalization dropped from 18 days prior to AOT to 11 days during the first six months of AOT and 10 days for the seventh through twelfth months of AOT (Swartz et al. 2009, 26-29).

A randomized controlled study in North Carolina (part of the so-called “Duke Study”) in 1999 demonstrated that intensive routine outpatient services alone, without a court order, did not reduce hospital admission. However, when the same level of services (at least three outpatient visits per month, with a median of 7.5 visits per month) were combined with long-term AOT (six months or more), hospital admissions were reduced 57 percent, and length of hospital stay was reduced by 20 days compared to individuals receiving the services alone. The results were even more dramatic for the subset of individuals with schizophrenia and other psychotic disorders. For them, long-term AOT reduced hospital admissions by 72 percent and length of hospital stay by 28 days compared with the services alone. The participants in the North Carolina study were from both urban and rural communities and “generally did not view themselves as mentally ill or in need of treatment” (Swartz et al. 1999).
A 1986 study in Washington, D.C., found that the average patient’s number of hospital admissions decreased from 1.81 per year before AOT to 0.95 per year after AOT (Guido and deVeau 1986). In a more recent Washington study of 115 patients, AOT decreased hospitalization by 30 percent over two years. The savings in hospital costs for these 115 patients alone was id="mce_marker".3 million (Guido and Stavis 2007). In Ohio, the decrease in hospital admissions was from 1.5 to 0.4 (Munetz et al. 1996) and in Iowa, from 1.3 to 0.3 over a 12 month period (Rohland 1998).
In an AOT program in Florida, AOT reduced hospital days from 64 to 37 days per patient over 18 months, a 43percent decrease. The savings in hospital costs averaged id="mce_marker"4,463 per patient (Esposito et al. 2008).
Only two studies have failed to find court-ordered outpatient treatment effective in reducing admissions. One was a Tennessee study in which “outpatient clinics [were] not vigorously enforcing the law,” and thus non-adherence had no consequences (Bursten 1986). The second was a Bellevue Hospital (New York City) study that pre-dated the enactment of Kendra’s Law and was based on a small AOT pilot program at that hospital (Policy Research Associates 1998). The study authors acknowledged that they could not “draw wide-ranging conclusions … [due to] the modest size of [the] study group.” As in the Tennessee study, there were no consequences to an individual for non-adherence, calling the significance of the findings into serious question. Although not statistically significant because of the small study group, the Bellevue study suggests that the court orders did in fact help reduce the need for hospitalization. Patients in the control group spent a median of 101 days in the hospital, while patients in the court-ordered group spent a median of 43 days in the hospital during the study.


A tragic consequence for many individuals with untreated mental illnesses is homelessness. At any given time, there are more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. In New York, when compared to three years prior to participation in the program, 74 percent fewer AOT recipients experienced homelessness (New York State Office of Mental Health 2005).


A study of the New York State Kendra’s Law program published in 2010 concluded that the “odds of arrest in any given month for participants who were currently receiving AOT were nearly two-thirds lower” than those not receiving AOT (Gilbert et al. 2010).
According to a New York State Office of Mental Health 2005 report on Kendra’s Law, arrests for AOT participants were reduced by 83 percent, plummeting from 30 percent prior to the onset of a court order to only 5 percent after participating in the program (New York State Office of Mental Health 2005, 18).
In a Florida report, AOT reduced days spent in jail among participants from 16.1 to 4.5 days, a 72 percent reduction (Esposito et al. 2008).
Similarly, the Duke study in North Carolina found that, for individuals who had a history of multiple hospital admissions combined with arrests and/or violence in the prior year, long-term AOT reduced the risk of arrest by 74 percent. The arrest rate for participants in long-term AOT was 12 percent, compared with 47 percent for those who had services without a court order (Swanson et al. 2001).


The 2005 New York State Office of Mental Health report also found that Kendra’s Law resulted in dramatic reductions in harmful behaviors for AOT. Among AOT recipients at six months of assisted outpatient treatment compared to a similar period of time prior to the court order: 55 percent fewer recipients engaged in suicide attempts or physical harm to self; 47 percent fewer physically harmed others; 46 percent fewer damaged or destroyed property; and 43 percent fewer threatened physical harm to others. Overall, the average decrease in harmful behaviors was 44 percent (New York State Office of Mental Health 2005, 16).
A 2010 study by Columbia University’s Mailman School of Public Health reached equally striking findings about the impact of Kendra’s Law on the incidence of violent criminal behavior. When AOT recipients in New York City and a control group of other mentally ill outpatients were tracked and compared, the AOT patients – despite having more violent histories – were found four times less likely to perpetrate serious violence after undergoing treatment (Phelan et al. 2010).
The Duke Study in North Carolina found that long-term AOT combined with intensive routine outpatient services was significantly more effective in reducing violence and improving outcomes for severely mentally ill individuals than the same level of outpatient care without a court order. Results from that study showed a 36 percent reduction in violence among severely mentally ill individuals in long-term AOT (180 days or more) compared to individuals receiving AOT for shorter terms (0 to 179 days). Among a group of individuals characterized as “seriously violent,” 63.3 percent of those not in long-term AOT repeated violent acts, while only 37.5 percent of those in long-term AOT did so. Long-term AOT combined with routine outpatient services reduced the predicted probability of violence by 50 percent (Swanson et al. 2001b).
The North Carolina study further demonstrated that individuals with severe psychiatric illnesses who were not on AOT "were almost twice as likely to be victimized as were outpatient commitment subjects." Twenty-four percent of those on AOT were victimized, compared with 42 percent of those not on AOT. The authors noted "risk of victimization decreased with increased duration of outpatient commitment” and suggested that "outpatient commitment reduces criminal victimization through improving treatment adherence, decreasing substance abuse, and diminishing violent incidents" that may evoke retaliation (Hiday et al. 2002).


AOT has also been shown to be effective in increasing treatment compliance. In New York, according to the 2005 New York State Office of Mental Health report, AOT led to a 51 percent increase in recipients’ exhibition of good service engagement, and more than doubled the exhibition of “good” adherence to medication (New York State Office of Mental Health 2005, 11-13).
In North Carolina, only 30 percent of AOT patients refused medication during a six-month period, compared to 66 percent of patients not under AOT (Hiday and Scheid-Cook 1987). In Ohio, AOT increased attendance to outpatient psychiatric appointments from 5.7 to 13.0 per year; it also increased attendance at day treatment sessions from 23 to 60 per year (Munetz et al. 1996).
AOT also promotes long-term voluntary treatment compliance. In Arizona, "71 percent [of AOT patients] . . . voluntarily maintained treatment contacts six months after their orders expired" compared with "almost no patients" who were not court-ordered to outpatient treatment (Van Putten et al. 1988). In Iowa, "it appears as though outpatient commitment promotes treatment compliance in about 80 percent of patients while they are on outpatient commitment. After commitment is terminated, about three-quarters of that group remained in treatment on a voluntary basis” (Rohland 1998).
The New York Independent Evaluation also yielded interesting findings on the likelihood of voluntary compliance after AOT is allowed to expire. For individuals who received AOT for periods of six months or less, the researchers found that post-AOT sustainability of improvements in medication adherence depended on whether intensive outpatient services were continued on a voluntary basis. Those who continued with intensive services maintained their substantial increase in medication adherence relative to the pre-AOT period (from 37 to 45 percent); those who discontinued such assistance dropped back to near the pre-AOT levels (33 percent). Patients who received AOT for more than six months, however, experienced increased medication adherence whether or not intensive services were continued. The medication adherence rate was higher for those who continued intensive services than for those who did not (50 percent vs. 43 percent), but both groups maintained substantial improvements from the pre-AOT rate (37 percent) (Swartz et al. 2009, 39-44).
Assisted outpatient treatment improves substance abuse treatment outcomes. Individuals who received a court order under New York’s Kendra’s Law were 58 percent more likely to have a co-occurring substance abuse problem compared with a similar population of mental health service recipients not receiving AOT. Furthermore, the prevalence of substance abuse at six months in AOT as compared to a similar period of time prior to the court order decreased substantially: 49 percent fewer abused alcohol (from 45 percent to 23 percent), and 48 percent fewer abused drugs (from 44 percent to 23 percent) (New York State Office of Mental Health 2005, 16).


A study published in 2004 examined the impact of AOT on those who serve as primary caregivers for people with severe mental illness (typically, family members). The level of reported stress was compared for caregivers of individuals who received AOT of at least six months, those who received brief AOT, and those who received no AOT. The results indicated that extended AOT (six months or more) significantly reduced caregiver stress. Not surprisingly, improved treatment adherence was also found to reduce caregiver stress. Notably, the study showed that AOT operates as an independent factor from treatment adherence in reducing stress. That is, AOT “contributes significantly to reduced caregiver strain, over and above its effect on treatment adherence” (Groff et al. 2004).

Find Frequently Asked Questions about assisted outpatient treatment here.  


Bursten, Ben. 1986. “Posthospital Mandatory Outpatient Treatment.” American Journal of Psychiatry 143: 1255-1258.
Esposito, Rosanna, Westhead, Valerie, and Jim Berko. 2008. “Florida’s Outpatient Commitment Law: Effective but Underused” (letter). Psychiatric Services 59: 328.
Gilbert, Allison R., Moser, Lorna L., Van Dorn, Richard A., Swanson, Jeffrey W., Wilder, Christine M., Robbins, Pamela Clark, Keator, Karli J., Steadman, Henry J., and Marvin S. Swartz. 2010. “Reductions in Arrest Under Assisted Outpatient Treatment in New York.” Psychiatric Services 61: 996-999.
Groff, April, Burns, Barbara, Swanson, Jeffrey, Swartz, Marvin, Wagner, H. Ryan, and Martha Tompson. 2004. “Caregiving for Persons with Mental Illness: The Impact of Outpatient Commitment on Caregiving Strain.” Journal of Nervous and Mental Disease 192: 554-562.
Hiday, Virginia A. and Teresa L. Scheid-Cook. 1987. “The North Carolina Experience with Outpatient Commitment: A Critical Appraisal.” International Journal of Law and Psychiatry 10: 215-232.
Hiday, Virginia A., Swartz, Marvin S., Swanson, Jeffrey W., Borum, Randy, and H. Ryan Wagner. 2002. “Impact of Outpatient Commitment on Victimization of People with Severe Mental Illness.” American Journal of Psychiatry 159: 1403-1411.
Munetz, Mark R., Grande, Thomas, Kleist, Jeffrey, and Gregory A. Peterson. 1996. “The Effectiveness of Outpatient Civil Commitment.” Psychiatric Services 47: 1251-1253.
New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.
Phelan, Jo C., Sinkewicz, Marilyn, Castille, Dorothy, Huz, Steven, and Bruce G. Link. 2010. “Effectiveness and Outcome of Assisted Outpatient Treatment in New York State.” Psychiatric Services 61: 137-143.
Policy Research Associates. 1998. Research Study of the New York City Involuntary Outpatient Commitment Pilot Program. Policy Research Associates, Inc.
Rohland, Barbara M. 1998. The Role of Outpatient Commitment in the Management of Persons with Schizophrenia. Iowa City: Iowa Consortium for Mental Health, Services, Training, and Research.
Swanson, Jeffrey W., Borum, Randy, Swartz, Marvin S., Hiday, Virginia A., Wagner, H. Ryan, and Barbara J. Burns. 2001a. “Can Involuntary Outpatient Commitment Reduce Arrests Among Persons with Severe Mental Illness?” Criminal Justice and Behavior 28: 156-189.
Swanson, Jeffrey W., Swartz, Marvin S., Borum, Randy, Hiday, Virginia A., Wagner, H. Ryan, and Barbara J. Burns. 2001b. “Involuntary Outpatient Commitment and Reduction of Violent Behaviour in Persons with Severe Mental Illness.” British Journal of Psychiatry 176: 224-231.
Swartz, Martin S., Swanson, Jeffrey W., and Virginia A. Hiday. 2001. “A Randomised Controlled Trial of Outpatient Commitment in North Carolina.” Psychiatric Services 52: 325.
Swartz, Marvin S., Swanson, Jeffrey W., Steadman, Henry J., Robbins, Pamela Clark, and John Monahan. 2009. New York State Assisted Outpatient Treatment Program Evaluation. Duke University School of Medicine.
Swartz, Marvin S., Swanson, Jeffrey W., Wagner, H. Ryan, Burns, Barbara J., Hiday, Virginia A., and Randy Borum. Swartz MS, Swanson JW, Wagner RH et al. 1999. “Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings from a Randomized Trial With Severely Mentally Ill Individuals.” American Journal of Psychiatry 156: 1968-1975.
Van Putten, Robert A., Santiago, Jose M., and Michael R. Berren. 1988. “Involuntary Outpatient Commitment in Arizona: A Retrospective Study.” Hospital and Community Psychiatry 39: 953-958.
Zanni, Guido and Leslie deVeau. 1986. “Inpatient Stays Before and After Outpatient Commitment.” Hospital and Community Psychiatry 37: 941-942.
Zanni, Guido and Paul F. Stavis. 2007. “The Effectiveness and Ethical Justification of Psychiatric Outpatient Commitment.” American Journal of Bioethics 7: 31-41.

Copyright 2011 Treatment Advocacy Center - reproduction permitted with attribution

Tuesday, January 24, 2012

Mentally ill flood ERs as states cut services

Reported by MSNBC in December. Yes, folks, it's happening.  Closing our inpatient facilities is not the answer.

Mentally ill flood ERs as states cut services

"Now you are adding in patients who are unsafe to leave but yet have nowhere to go," he said. "I consider patients with acute psychiatric needs as really the forgotten patient population in the U.S. right now."
And many hospitals are not prepared for the increased caseload of psychiatric patients, says Randall Hagar, director of government affairs for the California Psychiatric Association.
California cut $587 million in state-funded mental health services in the past two years, the most of any state, according to the National Alliance on Mental Illness, a patient advocacy group.
"They don't have secure holding rooms. They don't have quiet spaces. They don't have a lot of things you need to help calm down a person in an acute psychiatric crisis," Hagar said.
"Often you have a patient strapped to a gurney in a hallway outside of the emergency department where social workers are desperately trying to find an inpatient bed," he said.

Friday, January 20, 2012

Life under the bridge: Homeless and mentally ill in SLO County | The Tribune &

According to Dee Torres, director of homeless services for the Community Action Partnership of San Luis Obispo County (formerly the Economic Opportunity Commission), one of the threads that runs through each of these individual’s lives is mental illness.
According to the most recent countywide Homeless Enumeration, children account for some 49 percent of the 4,000 people who reported themselves as homeless. That number may be accurate, and it’s a harsh indictment of our society at large and this county in particular if that’s the case.But Torres and those who work with the homeless at the Prado Day Center, the Maxine Lewis Memorial Shelter and other homeless outreach services around the county aren’t seeing as many homeless children as they are those who are abjectly homeless and mentally ill.In fact, case management statistics show that 64 percent of those seeking help are found to be clinically mentally ill, with many of those abusing alcohol or drugs.Now, if you’re looking to blame Ronald Reagan for closing mental hospitals during his tenure as governor during the 1970s, thus releasing a torrent of mentally ill homeless people onto California streets, keep your powder dry. Lawsuits by the ACLU and other liberals were just as responsible for closing hospitals.The antidote to institutionalization, they believed at the time — and still do — is one of fully funding medical treatment. Before that happens, though, those who live along the banks of San Luis Creek have to be located and brought within the system. And that’s what Torres is doing.

Life under the bridge: Homeless and mentally ill in SLO County | The Tribune &

Thursday, January 19, 2012

Calling all mental health provider volunteers & Knoxville city/county Leadership!

Kudos to Matt w/ Cherokee Health Systems for volunteering under the bridge on a frigid, cold Wednesday evening at Lost Sheep Ministry.

More volunteers from our city's mental health care providers are sorely needed on a weekly basis to socialize with these friends, of whom a large percentage are living on the streets of Knoxville with untreated mental illness. Last night, we did not have enough ladies clothes and/or coats to distribute. Think about this when you wake up and it is 21 degrees on the thermometer outside your window!

We urge you to come next Wednesday for 2 very critical hours between 6 and 8pm. We need you! They need you!

Calling all Knox County Commissioners - in fact, all Knoxville Leadership - we solicit your presence as well.

With Lakeshore closing, you need to see firsthand the future that lies ahead for the serious and persistent untreated mentally ill of our region.

You can find us under the I-40 bridge off Blackstock Street in downtown Knoxville every Wednesday evening.  Dress warmly and bring extra coats.

Tuesday, January 17, 2012

Loughner a “textbook” case paranoid schizophrenic

Slate magazine's must read interview with Dr. E. F. Torrey on Jared Loughner.

Loughner a “textbook” case paranoid schizophrenic

Why psychiatrists can’t predict mass murderers

Manic Episode, Death in the Devil's Chair: a family's worst nightmare is realized.

Christie had been taking medication for his depression, but the doctor who was treating him had recently moved. That left no one to manage Christie's spiraling emotional state, and no one to control the possible side effects of his medication. Christie's wife worried about his trip to Florida, to the point where she contacted police in Lee County herself to ask that they keep an eye out for her husband. At her request, a captain from the Girard, Ohio police department also called Lee County officials and asked them to take Christie to a hospital if they found him.Christie was first arrested on March 25, for public intoxication. Though there's evidence Christie had been drinking, he was also beginning his mental deterioration, and may have merely been disoriented. One fast-food worker he interacted with that night said she thought he was suffering from Alzheimer's. Though confused (he couldn't remember his wife's or brother's phone number), Christie did inform the jail attendants of his various medical conditions, and gave them a list of the medications he was taking. He was released the next day.Christie was then arrested again on March 27, this time for misdemeanor trespassing. Nicholas DiCello, whose Cleveland firm Spangenberg Shibley & Liber has filed a civil rights lawsuit on behalf of Joyce and Christie's estate, says the second arrest was for a minor offense. "It was for trespassing at the hotel where was staying," DiCello says. "He was having another mental episode. He was bewildered, acting crazy, and so the hotel got fed up and asked him to leave. When he didn't go, they called the police."According to DiCello, the jail staff and the staff for Prison Health Services, the private company contracted to provide medical service to the jail, ordered no advanced physical or mental health screening for Christie before he was jailed, despite the long list of medical conditions already in his file from his prior arrest. There is also no indication that anyone was made aware of Joyce Christie's notification of Lee County officials, in which she informed them about her husband's conditions. According to the lawsuit, after the second arrest, Lee County deputies locked Christie's medications in his truck. During his 43 hours in custody, he was never given medication.
Christie was uncooperative and nonsensical from the time he was arrested, but at some point after his incarceration, he became combative. Lee County deputies responded by either directly spraying him or fogging his cell with pepper spray at least 10 times. (According to police, Christie was sprayed eight times. A cell mate was sprayed two other times, which may have affected Christie.) He was never allowed to "decontaminate" -- to wash the spray off. Other inmates in the jail, who weren't targeted with the spray, told the Fort Myers News-Press the blasts were so strong that the secondary effects caused them to gag.
The deputies then put Christie into a restraining chair, a controversial device that binds inmates at both wrists, both ankles, and across the chest. In depositions, the other inmates, along with a deputy trainee named Monshay Gibbs, testified that Christie was sprayed at least two more times after he had been strapped to the chair. He was also stripped naked, and outfitted with a "spit mask," a hood designed to prevent inmates from spitting on jail personnel. In Christie's case, the mask kept the pepper spray in close proximity to his nose and mouth, ensuring he would continue to inhale it for the full six hours he was in the restraint chair.
According to Gibbs' testimony, Christie pleaded with the deputies, telling them he had a heart condition and numerous other medical problems, and that the spit mask made it difficult for him to breathe. Other inmates have confirmed Gibbs' account, adding that Christie began to turn purple.
When Joyce Christie heard of her husband's second arrest, she flew down to Florida to find him. "She was actually relieved to hear he had been arrested," DiCello says. "She thought they had responded to her pleas for help, that they would take him to a hospital to be treated." She eventually made her way to the Lee County jail. Joyce Christie would later learn that at one point in the night, when she was pleading with police to take her husband to the hospital, at the same time and in the same building he was being tortured to death in the restraint chair.
"She left frustrated," DiCello says. "They weren't listening to her. She didn't know what to do."
In the early afternoon of March 29, Nick Christie went into respiratory distress. He was taken to the Gulf Coast Medical Center in Fort Myers. Joyce Christie told journalist Jane Akre that according to hospital staff, her husband was so covered in pepper spray that doctors had to repeatedly change their gloves as they became contaminated. Christie would suffer multiple heart attacks over the next two days before he was finally declared brain dead and his life support was removed on March 31. Two days after Christie had been transported out of the jail, Deputy Medical Examiner Dr. Robert Pfalzgraf noted in his autopsy report that Christie still had brown-orange liquid pepper spray all over his body.
Pfalzgraf determined that Christie's heart gave out due to stress from his exposure to pepper spray. He ruled the death a homicide.
The Devil's Chair"I look at this story, and all I can say is, what in the world were they thinking?" says David Klinger, a former police officer who now teaches at the University of Missouri-St. Louis. Klinger specializes in the use of force. "As a general rule, you don't use pepper spray on someone who is restrained. There might be some limited circumstances where, say, you have a suspect in handcuffs who is banging his head against the window of a patrol car. You might give him a quick burst of pepper spray. But never, never someone who is secured in a restraint chair. It just makes no sense at all."
The Lee County deputies appear to have violated accepted use of force guidelines a number of different ways, including the length of time they kept Christie strapped to the chair, pepper spraying him after he had been restrained (as well as their failure to clean the pepper spray off of him), their failure to properly evaluate him for mental and physical health problems, and their failure to allow him to take his medication.
While the Florida Sheriff's Association told HuffPost that it has no guidelines on the use of restraint chairs, there seems to be a strong consensus that the use of pepper spray, stun guns, or other compliance tools after a suspect has been restrained is at minimum excessive force, and possibly a crime.
The U.S. Court of Appeals for the Eleventh Circuit has found that pepper spraying suspects suffering mental illness is a violation of their constitutional rights, and several federal appeals courts have ruled that spraying someone who is already restrained is an excessive use of force. The state of Vermont forbids the use of restraint chairs for punishment, and requires approval from a medical professional and a mental health professional before a chair can be used. In the event that an inmate poses an immediate risk, a mental health professional is to be contacted immediately after the inmate is strapped in. The Florida Department of Juvenile Justice forbids the use of restraint chairs and pepper spray on incarcerated minors entirely.
The Florida State Prison System doesn't use restraint chairs, either. A spokeswoman told theOrlando Sentinel in 2006 that the state's Department of Corrections has determined the chairs are a safety risk, and inappropriate for prisoners with mental illness. The problem, some experts say, is that inmates with mental illness are particularly prone to "excited delirium," an escalating set of respiratory and cardiovascular symptoms that can lead to death. (Though the diagnosis is still controversial.)
Steve Yerger has been training law enforcement agencies on the use of force for 20 years, and gives what he says is the only course on restraint chairs in the country. Yerger says the complete restriction of movement to which the chair subjects inmates can trigger physiological effects -- both respiratory and circulatory -- and that the problem can be exacerbated in patients with mental health problems. "They can just go through the roof, and then they crash. You need to make sure you have constant monitoring, and that you always have medical professionals close by," Yerger says.
But inmates with mental illness are also more likely to present a threat to themselves or others, which means they're more likely to need restraint. A 2009 report by the Maryland Frederick News-Post, for example, found that in the previous year, 64 percent of inmates put in a restraint chair by the Frederick County Sheriff's Department had mental health problems.
While there's no universal policy on how long an inmate can safely be left in a restraint chair, the Oklahoma Department of Corrections limits it to two hours. Texas limits the time to five hours in any 24-hour period. Montana limits restraint to four hours. Iowa law also limits the time to four hours (though Iowa jails that exceed that limit appear to suffer little more than some public criticism.) Utah banned restraint chairs entirely after inmate Michael Valent died of blood clots -- the result of beingstrapped to a chair for 16 hours. Though in Utah too, several counties continued to use the chairafter the ban.
There have been a number of deaths over the years at least in part attributed to what critics call "the devil's chair" or the "torture chair." In a 2000 article for The Progressive Anne-Marie Cusac documented 11 deaths, including several inmates with mental illness as well as cases in which inmates were pepper sprayed after they had been restrained. Cusac notes that in the 1999 case of James Arthur Livingston, who died after being strapped to a restraint chair in Tarrant County, Texas, the first deputy who attempted to give Livingston CPR wrote in his report, "I then removed myself from the area and walked into the sally port, where I threw up from inhaling pepper gas residue from inmate Livingston."
In 2004, the Dayton City Paper wrote about three restraint chair-related deaths in Dayton County, Ohio, alone.
Restraint chair-related lawsuits alleging patterns of abuse have proliferated across the country, including in IowaGeorgia (PDF), ColoradoTexasCaliforniaNew Jersey and Maricopa County, Arizona, where the chairs were finally replaced in 2006 after three deaths and several million dollars paid out in settlements.
Florida has also had its share of restraint chair problems. Four of the 11 deaths Cusac chronicles in her 2000 article took place in Florida jails. In 2007, Lake County paid out a $500,000 settlement to the family of a woman who suffocated in a restraint chair, though the settlement didn't bar the county from using the chair in the future. The state has also been the scene of a years-long, high-profile controversy following the use of a restraint chair on the daughter of the Florida State Attorney in 2005.
Like Klinger, the former police officer, Yerger says the use of pepper spray in conjunction with the chair was particularly over the line. "This is a tool for restraint, and there's no reason to pepper spray someone once they're restrained. That's punishment, and it's a form of torture. At minimum, that sort of thing should cost someone his job. And it should probably lead to criminal charges."
But the pepper spray-restraint chair combination has happened in other jurisdictions as well. Last year, a Harrison County, Indiana, officer was accused of putting pepper spray in a hood, then putting it over the head of an inmate already nude and bound to a restraining chair. In the following months, more accusations came out against the department, many again involving abuse of the restraining chair. In 2006, deputies in another Harrison County -- this one in Mississippi -- emptied an entire can of pepper spray into a hood that they then placed over the head of Jesse Lee Williams, while he was confined to a restraint chair. Williams, who was also severely beaten, later died of kidney failure.
Yerger says the other problem in Lee County is that once Christie had been securely restrained, he needed medical treatment. While the officers in Lee County were clearly out of line, Yerger says, the problem in many other cases is more a lack of training.
"Several years ago, I was researching the restraint chair for a case where I was going to be an expert witness. I found that all of these police departments across the country were using the chairs, but none of them were getting any training," Yerger says. "There's no training on the proper way to put someone into the chair, but more importantly, you have these people who have mental problems, or who are on alcohol or drugs. These are medical problems, that require medical attention. This isn't criminal behavior. But that's sometimes how it's treated."
This collection of deaths, injuries and reports of abuse involving restraint chairs has moved bothAmnesty International and the United Nations Committee Against torture to call for a ban on the devices.
In her 2000 article, Cusac points to a deposition of Dan Corcoran, president of AEDEC International Inc., the Beaverton, Oregon, company which manufactures the Prostraint Violent Prisoner Chair. Corcoran acknowledges that the only testing he did of the chair before marketing it was to put some friends in it. He says the chair had never been tested in any scientific way for its effect on someone impaired by drugs, alcohol or mental illness (in fact, he specifically recommends the chair for the first two), or for other hazards like deep vein thrombosis, the sometimes-fatal blood clotting that can occur after remaining in the same position for more than a few hours.
But both Yerger and Klinger say calls for banning the chair are misplaced. They say restraint is sometimes critical when a prisoner poses a threat to himself or others, and there's nothing particularly sinister about the restraint chair. "Once you take care of the immediate threat -- and you really do need to take care of that -- then you treat the case like it needs to be treated. That means if it's someone having a mental crisis, you get them to a hospital," Yerger says.
"Any new device or piece of technology can be helpful, or it can be abused, whether it's a restraint chair, a Taser, or baton," says Klinger. "If you have officers who are willing to punish and abuse a restrained prisoner, it's going to happen whether he's in a restraint chair, handcuffs, or a restraint bed or gurney. The device isn't the problem. It's the officers."
"It's really about culture," says Yerger. "You need to instill a distinct code, especially in a correctional facility, that emphasizes control over punishment."
Yerger cites Philip Zimbardo's famous 1971 Stanford Prison Experiment which, though it later came under criticism, showed how quickly students randomly chosen to be guards in a hypothetical prison resorted to abusing students randomly chosen to be prisoners. "It's a constant thing. It has to be hammered home, over and over."
In Christie's case, that puts the bulk of the blame on the deputies and Lee County Sheriff Mike Scott, not on the restraint chair.
No AccountabilityWhen Joyce Christie finally got a phone call in March 2009 letting her know that her husband had been taken to the hospital, the call was anonymous, and the caller didn't say what hospital. She used caller I.D. to determine the call had come from the Gulf Coast Medical Center. When she arrived, the police wouldn't let her see her husband. Fortunately, someone in the waiting room overheard her conversation and gave her the card for a bail bondsman. She left to get the bond, and only after posting bond was she allowed to see him. By then, Nick Christie was close to death. As a deputy at the hospital got up to leave, he told Christie to make sure her husband -- now with eyes taped shut and tubes protruding from his face -- showed up for his court date, or else he'd be arrested.
Scott's office conducted its own internal investigation of Nick Christie's death and, perhaps not surprisingly, found no wrongdoing on the part of any Lee County deputy. That conclusion may come back to bite the county. Municipalities have what's known as sovereign immunity from civil lawsuits. But one way to get around sovereign immunity in a civil rights case is to show that a government agency has displayed a pattern or practice of improperly training employees about citizens' rights. Since using pepper spray on a restrained inmate and neglecting to get him medical attention are both clearly established civil rights violations, in concluding that none of his officers acted outside of department policy, Scott may have given DiCello an opening.
And in fact, none of the deputies involved with Christie's death were disciplined in any way. Florida State Attorney Stephen Russell declined to press criminal charges. DiCello says that Russell's review was based almost entirely on the sheriff's department report. Samantha Syoen, communications director for Russell's office, says the investigation did use much of the sheriff department's investigation, but that the possible bias of that report was taken into consideration when deciding whether or not to pursue criminal charges. "We've prosecuted police officers before." Syoen says. "We've prosecuted judges, we've even prosecuted our own."
Syoen says the state attorney's office didn't clear the deputies involved with Christie's death, it only determined that under Florida law there wasn't enough evidence for criminal charges.
"Our office was very concerned about what happened to Mr. Christie," she said. "But the memo concluded that this would be a matter better settled at the federal level, either with possible criminal charges or with a lawsuit."
According to DiCello, the office of U.S. Attorney Robert O'Neill has yet to show any interest in the case. (O'Neill's office referred HuffPost to the FBI's Fort Myers regional office. That office did not return HuffPost's request for comment.)
Joyce Christie returned to Girard, Ohio shortly after Nick, her husband of 40 years, had died. A few days after she returned, she received something in the mail from Lee County, Florida. It was a warrant for her husband's arrest.