1. Rosalie Toupin
Senior Project Script, June 2016
The Use of Mechanical Restraints in Psychiatric Hospitals
When I began my senior project, I was focused on Schizophrenia, a mental disorder that
distorts one’s perception of reality, and how it affects a person’s life and mind. I began reading
an autobiography called The Center Cannot Hold by Elyn Saks, about her experience of living
with Schizophrenia. As I was reading, I was shocked by her descriptions of being mechanically
restrained in psychiatric hospitals.
Elyn Saks, a college professor at the University of Southern California Gould Law
School, founder of The Saks Institute for Mental Health Law, Policy, and Ethics, and successful
author of her autobiography The Center Cannot Hold, experienced being mechanically restrained
several times throughout her time spent at psychiatric hospitals. Professor Saks has suffered with
Schizophrenia from a young age. When she was just eight years old, Saks had her first delusion
of there being a man outside her house, trying to kill her. During college, she began experiencing
hallucinations but she was able to manage them and graduate as the valedictorian of her class at
Vanderbilt University in Nashville, TN. After college, Saks was accepted into Oxford
University’s Corpus Christi College to pursue a graduate degree in philosophy. During grad
school, Saks’ delusion and hallucinations started to take over her life. After having suicidal
thoughts, Saks checked herself into Oxford Medical School’s psychiatric division, Warneford
Hospital, as a day patient. Regulated medication plus weekly treatment sessions with her
psychoanalyst, Mrs. Elizabeth Jones, allowed Saks to complete her education. After graduating
from Oxford, Saks moved back to the US to attend Yale Law School, but the drastic change in
2. environment was too much for her to handle. In her autobiography, Saks describes hallucinating
at Yale’s Student Health Center. She writes:
“I crawled under the desk and started to moan and rock. The faceless creatures
hovering near, invisible to everyone but me, were about to tear me to pieces.
‘They’re killing me. They’re killing me! I’ve got to try. Die. Lie. Cry.’”
Elyn Saks was mechanically restrained for the first time at Yale-New Haven Hospital.
Her legs and arms were strapped to a metal bed with thick leather straps and she was forced fed
antipsychotic drugs.
The practice of mechanical restraints has been used in psychiatric hospitals since the 19th
century. Patients who pose as a threat to themselves or to others are mechanically restrained at
the arms, legs, and sometimes even chest to try and prevent harm for both the patient and the
staff. For patients with Schizophrenia, this can be an often occurrence since schizophrenia
directly affects the mind and how one perceives reality. People with Schizophrenia often
experience hallucinations such as seeing a man with a knife outside their window or a swarm of
bees closing in on them. Many also experience delusions such as believing that someone is out to
get them or that they have killed hundreds of people. Patients may lash out during a psychotic
break due to feeling overwhelmed by fear and confusing, putting themselves and others in
danger.
However, mechanical restraints often cause more harm than good for the patients
restrained. Elyn Saks experienced psychological harm along with physical harm from being
mechanically restrained, but restraints can introduce more significant risks, including death.
In 1998, the Hartford Courant, Hartford, Connecticut's local newspaper, published a
series of articles that reported adult and children fatalities due to mechanical restraints.
3. According the article, between 1989 and 1999, there were 142 deaths reported in the United
States during or immediately following a restraint.
In 2010, Elyn Saks gave a Ted Talk on her experience of being mechanically restrained
where she reported
“Every week in the United States, it's been estimated that one to three people die
in restraints. They strangle, they aspirate their vomit, they suffocate, they have a
heart attack. It's unclear whether using mechanical restraints is actually saving
lives or costing lives.”
Under normal circumstances, one would expect that a doctor, seeing a patient choking on
vomit, or unable to breathe, would be able to help that person. But dealing with a patient
suffering from mental illness, is not a normal circumstance. There are two main reasons for this:
the first being the logistics behind running a major hospital. In a hospital ward caring for 100
patients or more, it’s difficult to devote hours of individual time to just one patient. Doctors and
nurses often can’t watch a restrained patient 24/7. Instead, they can only check in on the patient
occasionally while still tending to the other patients of the ward.
According to the Massachusetts Department of Mental Health policy on mechanical
restraints, nurses are required to perform safety checks on restrained patients every 15 minutes.
This includes checking the patient’s vital signs, comfort, body alignment, circulation and
behavioral status. However, there is still a significant risk of injury, including death, that can
occur in a 15 minute time frame, including suffocation, respiration, or heart attack.
The second reason why restrained patients aren’t always properly monitored is due to the
patient’s psychosis. Psychosis when you aren’t fully able to distinguish fantasies from realities.
For Elyn Saks, her “fantasies were real and everything [that she imagined] was actually
4. happening”. Psychotic patients can experience delusions that affect how they feel physically,
such as not being able to feel a certain part of the their body or feeling like they can’t breathe
when in reality, their body and vitals are physically normal. For the medical staff, this aspect of
psychosis can make it difficult to determine whether a psychotic patient’s medical complaints are
legitimate or just a manifestation of their psychological issues.
And so, despite numerous reports citing the psychological and physical harm that results
from being mechanically restrained--including a significant number of fatalities--the fear of
having to deal with potentially violent patients has resulted in their continued use. This dilemma
has been observed on a national scale by Federal and State courts since the 1970s. In 1971, the
use of restrictive interventions was a central issue in the Supreme Court Case of Wyatt v.
Stickney. Then, in 1982, the Supreme Court recognized the harmful aspects of mechanical
restraints in the Youngberg v. Romeo case. The Supreme Court concluded that “[t]he right to be
free from undue bodily restraint is the core of the liberty interest protected by the Due Process
Clause from arbitrary governmental action.”
Hospitals have attempted to reduce the risk of mechanical restraints through different
policies, but many aren’t fully successful. For example, the Massachusetts’ Department of
Mental Health’s policy on Restraint and Seclusion, which is regulated throughout four
Massachusetts State Psychiatric Hospitals, states that “the Department of Mental Health (DMH)
is committed to eliminating the use of restraint.” This policy then goes more in depth on the
specific rules of restraint procedures, including the requirement of a calm physical space with
appropriate lighting, the use of an Individual Crisis Prevention Plan, and proper documentation
of the restraint during and after the event for both the patient and the staff. This policy has
reduced the use of restraints; however, during my research, I visited a local DMH hospital and
5. learned that they performed around 80 restraints on 34 patients just last February. So, as good as
the DMH policy may sound, it still isn’t enough.
Despite the issue of mechanical restraints being recognized by Federal and State courts,
and hospitals’ attempts to regulate their use, the problem continues to exist. The question I was
then faced with, is why? It simply didn’t make sense that a problem that everyone seemed to
know about would continue to be a problem.
To solve this dilemma, I realized that I needed to collect and analyze reliable research to
formulate a supported argument and solution. I began by looking for case studies with data on
the use of mechanical restraints to try and collect information and numbers on the subject but I
ran into a major roadblock -- the research I needed to back up my argument against mechanical
restraints didn’t exist. I kept digging and digging until I finally came to the conclusion that I
can’t create a supported argument yet because the research on mechanical restraints is too
inconsistent and outdated to use reliably.
On of the sources I was trying to extract information from was the literature review on
the use of mechanical restraints on adult psychiatric inpatients conducted by The City University
in London in 2009. The collected data was from twenty four studies that reported incidents of
restraint and while the majority of the studies were conducted in the United States, the review
reported on data gathered from several different countries around the world, including Finland,
Germany, Switzerland, and Japan.
The majority of the studies consistently reported the proportion of patients restrained, but
as the literature review states, “only limited conclusions [could] be drawn from [the studies]” due
to the “widely differing methods of presenting [the] information” including the time period that
each case focused on. For example, from the data collected by The City University in London,
6. one United States case study performed in 1982/3 reported data over a one month period while a
different US case study from 2001 collected data over 6 years and a Finnish case study collected
data over 15 years.
The case studies were all based off of different research designs. Some studies focused on
only violent patients while other studies took all psychiatric patients into consideration. One case
study compared data collected from German psychiatric hospitals to that of Swiss psychiatric
hospitals, but the research was limited to only the restraint procedures of Schizophrenic patients.
Another case study conducted on acute wards in the UK, Italy, and Greece only took into
consideration patients who were admitted for two or more weeks. One study doesn’t even list the
number of patients restrained, but rather just the number of hospitals that reported restraints.
In addition to inconsistent research methods, much of the data for mechanical restraints is
too outdated to apply today’s situations. For example, in Elyn Saks book The Center Cannot
Hold, Saks recalls being restrained for over 30 hours at the Yale Psychiatric Institute. Saks
arrived at YPI where she was taken into a seclusion room and asked to restrain herself. She was
completely calm and actually quite tired, just wanting to be left alone so she could sleep, but the
nurse on call told her “Either put yourself in restraints or we’ll put you in them. It’s up to you.”
Saks resisted, but with the help of the hospital staff, the nurse restrained Saks’ arms, legs, and
chest. 30 some hours later, Saks was finally released from restraints.
I wanted to be able to compare YPI’s current restraint policy to Saks’ experience so I
could see if the hospital has made a major change or not in the past 30 years. However, after
digging around for an hour or so, all I could find was the hospital’s Medical Staff Education
powerpoint that included one slide dedicated to the use of restraints.
7. On this slide was the question “What is my role?”, directed to the hospital's staff, where it
reads
“Y-NHH is committed to prevent, reduce, and eliminate the use of restraints and
seclusion whenever clinically feasible and to promote the rights, dignity and
physical integrity of the patient to the fullest extent possible.”
This vague and unhelpful statement is followed by specific staff requirements, such as
conducting a face-to-face assessment with the patient within one hour of the restraint and a
debriefing session with the patient and staff within 24 hours of the restraint. However, nowhere
in this training powerpoint does it discuss the limitations of the restraint procedure itself,
including how long a patient can be restrained for and why qualifies as “clinically feasible”.
The slide does however include the directions for finding the hospital's official restraint policy
but when I visited the given website, I was asked for a username and password. I had reached a
dead end.
I was unable to come to any conclusions about Yale Psychiatric Institute’s use of
mechanical restraints because the only information I was able to find was from 30 years ago. I
couldn’t assume their restraint policy was the same as it was three decades ago, but also I
couldn’t prove that things were any better today.
At this point, given the lack of consistent and up-to-date research, I expected that the
issue of mechanical restraints would not have improved. However, despite the lack of research
that a number of sources claimed, and that I experienced myself, a few organizations seem to
have found ways to drastically reduce, and in some cases virtually eliminate, the use of
mechanical restraints.
8. For example, in 1997, Pennsylvania's mental health care system was the first in the
country to introduce a revised policy on the use of mechanical restraints that outlined a
comprehensive program with “clear goals, specific strategies, and ongoing monitoring.” All
institutions operated by the Department were subjected to this new policy, specifically State
general hospitals and State-operated institutions for the mentally ill. The policy instructed that
“restraints shall be employed only when necessary to protect the patient/resident from injuring
himself or others” and are to be used only if all “other available techniques or resources have
failed.” The policy also includes an institution restrain plan describing specific procedures for
employees’ use, instructions about creating individual program plans for patients, and a
statement ruling that the Superintendent/Director of the hospital is administratively responsible
for insuring that restraints are only used in measures that follow the new policy.
In just five years after the introduction of the new policy, Pennsylvania's mental health
care system reported a 74% decrease in the total number of restraint and seclusion episodes and a
96% decrease in the total number of hours patients spent in restraint and/or seclusion.
Since Pennsylvania’s success in 1997, more and more hospitals have successfully revised
their policies on mechanical restraints. From 1999 to 2001, Creedmoor Psychiatric Center
reported a 67% decrease in the use of restraints and seclusions after updating their policy and
from 1998 to 2000, South Florida State Hospital reviewed their policy and went from conducting
fifteen or more restraints a month to one.
Revising restraint policies is not only helpful for patients, but according to authors of
Restraint and Seclusion - A Risk Management Guide, it is also an inexpensive change that can
help hospitals avoid potential legal issues. This plus readily available tools that help reduce
10. Center on Psychiatric Disability at the University of Illinois, Chicago. This program seeks to
“increase self-determination by helping individuals develop written plans that identify personal
stress triggers and strategies to manage agitation and anger.” Many of the patients in psychiatric
hospitals have experienced terrifying and dangerous situations, such as sexual, physical, and/or
emotional abuse. Therefore, each patient will have different triggers that reminds them of these
past experiences. It is important for the medical staff to be aware these triggers so that they can
help the patients avoid them and in doing so, help everyone in the hospital environment avoid
potentially dangerous situations.
The Advance Crisis Management Program was used at three university units -- an adult
unit, an adult research unit, and an adolescent unit. In just the first two quarters, the use of
restraint and seclusion declined significantly at all three of the units and remained low for the
rest of the year.
So there are comprehensive, successful policies and training procedures out there that
provenly eliminate the use of mechanical restraints. But these success stories are limited; the
successful policies listed above only apply to, perhaps, two dozen hospitals nationwide. This is a
start, but considering that, in the United States, there are 5,627 registered hospitals including 403
nonfederal psychiatric hospitals whose policies depend on whether the hospital receives funding
from the state or from a private investor, there’s a lot more that needs to be done. And these
changes need to be manageable in all states, regardless of size and population. The vast
differences in the number of hospitals regulated by states makes this a difficult issue. For
example, the Massachusetts’ Department of Mental Health regulates psychiatric activity in four
hospitals while Texas’s Department of State Health Services oversee twelve state psychiatric
hospitals. But even in Massachusetts, with the small number of state hospitals, there are also
11. privately funded psychiatric hospitals, such as Mclean Hospital which is affiliated with Harvard
University, that create their own policies. So, in America, we have thousands of different
hospitals abiding by hundred of different policies, with oversight from dozens of different
organizations. How are we supposed to implement these successful policies in all 5,627
hospitals?
The easiest way for the United States to ensure that all hospitals are properly avoiding
mechanical restraints would be to have the federal government create a successful, national
restraint policy. Since the 1980s, the American Psychiatric Association has pushed for this
solution.
In fact, in 1985, the American Psychiatric Association's Task Force conducted a survey
on the psychiatric uses of restraint and seclusion where they concluded that their survey
“supports the national need for comprehensive, widely disseminated, and hopefully, fully
implemented guidelines for the seclusion and restraint of patients.” Throughout the next 20
years, clinicians, researchers, consumers, and legal advocates continues to identify the overuse of
mechanical restraints in psychiatric hospitals.
In 2003, the American Psychiatric Association continued their research on the national
use of restraints in which they once again observed a “national intent to see that restraint and
seclusion are used appropriately, as infrequently as possible, and only when less restrictive
methods are considered and are not feasible.”
And so, it would seem that a national policy could have solved the problem of
implementing a standard restraint policy in all 5,627 US hospitals. The only problem with this
plan is that it isn’t actually possible. The fragmentation of our healthcare system is pervasive,
12. and complicated by bureaucratic issues, states rights, local laws, and private institutions all with
significant stakes in the healthcare system.
Since The United States has a democratic government, our federal officials, such as the
President, Members of Congress, and House Representatives, are re-elected every term, whether
it be every 2 years, 4 years, or 6 years depending on the position. However, most of our
government’s employees are not elected officials. We simply can’t have elections for every
member of the FBI, the Board of Education, or the IRS. Imagine if every employee knew that in
a number of years, they would have to be re-elected into their position. Any country or
organization with that kind of system simply couldn’t function.
That’s why we have bureaucracy. Bureaucracy is basically a system of government that
has several, complicated layers to it.
So in the US, the citizens elect the head of the executive branch, aka the President, who
then selects his/her cabinet members, including the Secretary of State. These two positions are
changed out every four or eight years, depending if the President is re-elected or not at the end of
his/her first term. However, along with the Secretary of State as the head, the Department of
State is made up of around sixty officials, including the Secretary for Public Diplomacy and
Public Affairs, the Secretary for Arms Control and International Security Affairs and the
Secretary for Political Affairs. These officials, plus the hundreds of employees in the State
Department, are the bureaucrats of the system. They are the people who are not elected into their
position and who keep their job throughout the different federal government terms. Bureaucrats
are essential to a functioning system because without them, our government would be uprooted
every few years.
13. It’s also necessary for these bureaucrats to have the opportunity of tenure so that the
newly elected official can’t just change out all of the bureaucrats at the beginning of their term. It
would defeat the purpose of bureaucracy if each President had the ability to hire and fire every
government employee.
However, with the necessity of tenure, and the reality of government turnover, it is
exceptionally difficult for a bureaucratic system to move quickly on anything. Imagine you are a
government employee working on the Affordable Care Act. How hard are you going to work on
this project when A. you are very difficult to fire thanks to your tenure and B. newly elected
officials might choose to undo everything in a few years? You probably wouldn’t take the
necessary means to push the project forward efficiently because there’s a strong possibility of all
your work being thrown out the window when the next President comes into office.
This complicated dilemma of bureaucracy gets carried over into pretty much every aspect
of US government, including our health care system.
US Health Care is fragmented into hundreds of different leaders and programs. If we
were to apply the US Health Care to this same diagram, State Government would be at the top,
which feeds down into the State’s specific department of health which would then feed down to
the different state hospitals, its Heads and Directors and its employees, both on the legal aspect,
the business aspect, and the medical aspect.
This diagram however is an oversimplification of the system because it doesn’t take into
consideration private hospitals. As I mentioned before, each state has a number of either state
psychiatric hospitals or state hospitals with psychiatric wards which are funded by the state’s
government. In Massachusetts, we have four state psychiatric hospitals: Worcester Recovery
Center and Hospital, Tewksbury Hospital Hathorne Unit, Lemuel Shattuck Hospital, and
14. Taunton State Hospital. These four hospitals all abide by the Department of Mental Health’s
policies. But there are also hospitals that are privately funded who do not have to follow the
state’s policies, such as Mclean Hospital. These private hospitals have a whole different set of
Heads and Directors and employees and regulations and policies… As you can see, it’s just
really complicated.
This complexity behind the whole system contributes to the difficulties of making
changes throughout US Health Care. There are so many different leaders and programs and
everything is so fragmented that making a major change, such as a national policy on mechanical
restraints is near impossible.
And it doesn’t help that there is a lack of urgency behind the problem of mechanical
restraints because restraints affect such a small population of people. For example, at a DMH
regulated hospital, there are 260 adult psychiatric beds, which, for the majority of time, are all
occupied. Last February, this hospital restrained 34 patients over a month period. That’s only
13% of the patients at the hospital. And not all of these patients were physically harmed by the
restraints. Maybe, 2 or 3% of the patients restrained experienced a significant amount of harm,
but none died from the procedure. This small percentage of directly affected patients make
people think “It’s not that big of an issue. There are bigger things to worry about right now.”
There is also a lack of urgency towards eliminating the use of mechanical restraints
because people are quick to believe that mechanical restraints protect the doctors and nurses
from the ‘harmful crazy people.’ But the medical staff aren’t really the ones at risk in these
situations. It’s the patients that need protection from their own psychosis.
When someone is experiencing a psychotic break, they can pose as a real threat to others
in their surrounding. A psychotic patient may be experiencing delusions, such as believing that
15. the doctors are trying to kill him, or hallucinations, such as a man running after them with a
knife. These delusions and hallucinations take over the patient’s ability to think clearly to a point
where fantasy is indistinguishable from reality. It would be like me telling you that my dress is
red and then everyone else in the room nodding along, confirming this statement. But you can
see with your own eyes that my dress is green, not red. Are you going to believe what everyone
else says they see, or are you going to believe what you see?
If this were to happen, you would probably feel pretty confused. Are you crazy? Are your
eyes playing tricks on you? What’s going on? Now imagine that there is a man running towards
you with a knife and a clear intent to kill you, and everyone else is just going about their day-to-
day business, paying zero attention to the murder heading straight at you. These oblivious
people, the ones who you are supposed to take care of you and to protect you, ignore your cries
for help, and all the while, the man gets closer and closer. You would be terrified and you
would do whatever is in your power to get these people to realize the danger you are in.
This fear, this hysterical confusion, is what a patient can experience during a psychotic
break. Psychotic patients aren’t just ‘harmful crazy people’; they are helpless and desperate for
relief from their pain that they may act out out of fear. These are the people we need to focus on
protecting. Restraining them only leaves them to suffer through their delusions alone. Instead of
just tying them up, the medical staff needs to do their absolute best to prevent these psychotic
breaks for the patients and when they do occur, the medical staff needs to be able to help the
patient without physically harming them.
The best and most effective way to encourage and teach medical staff how to do just this
is through successful policies and training procedures, like the Six Core Steps, the Roadmap to a
Restraint-Free Environment, and the Advance Crisis Management Program. If the United States
16. was able to implement these successful policies on a national basis, there would be a significant
reduction of the use of mechanical restraints.
However, this again gets back to the dilemma that result from a bureaucratic system. As I
mentioned before, US Healthcare consists of dozens of different levels of leadership, each
having different powers. For example, the State governments have the right to implement
policies in their publicly funded hospitals. However, the Directors of the specific hospitals have
the power to regulate said policies. The Heads of each ward have the power to regulate that
ward’s activities and the doctors/nurses have the power over the patient to ultimately decide
when restraints are necessary.
Here again, is a situation that could be resolved with the establishment of a national
policy on the use of mechanical restraints, in addition to some kind of federal regulation over all
US hospitals to ensure that the policy is carried out correctly. However, this would not only
disrupt the delicate power balance, but also result in a potential violation of the states’ rights
which is a constitutional issue--or at the very least, have trouble passing through a less-than-
active Congress. So before the US could actually implement a national policy, we would have to
revise the Constitution which is an incredibly daunting task because you are adding in a whole
nother bureaucratic system to the mix. And a much bigger one at that.
So we have this problem of mechanical restraints which we need to solve as a nation. The
first step to finding the solution would be through collecting and analyzing reliable research, but
such a thing doesn’t exist. Somehow, in spite of this dilemma, restraint policies that successfully
reduce and even eliminate the use of restraints exist today. In order to solve the problem of
restraints on a national scale, the US would have to implement a national restraint policy
that that mirrors these successful policies. However, since the US Healthcare system is a
17. fragmented, bureaucratic society that has a delicate power balance, implementing a national
policy just isn’t feasible.
Although this would seem like a dead end, both to my Senior Project and to the issue of
mechanical restraint regulation, there is another possible solution. In order to make a significant
change in a complex, bureaucratic system, such as healthcare, you have to take things one step at
a time. For mechanical restraints, this means revising policies state by state until the whole
nation agrees on similar policies that successfully eliminate the use of restraints in psychiatric
hospitals. Going through local governments or individual hospitals would take way too long and
be extremely inefficient. But, as we’ve already determined, making a quick, national change just
isn’t possible in a bureaucratic society. Instead, we have to focus on one state at a time because
once enough states make the change, the rest will catch up.
This slow but effective solution can be observed in several different historical examples,
including the abolishment of slavery and the legalization of Gay Marriage.
Back in 1641, Massachusetts was the first colony to legalize slavery. Africans were
shipped over from their homeland to America to serve the new settlers of the colonies. More than
100 years later in 1773, slaves in Massachusetts petitioned the government for their freedom, but
were unsuccessful. Around 50 years after this petition, the nation started to recognize the
necessity of the abolishment of slavery. In 1820, the Missouri Compromise abolished slavery in
all territory north of Missouri’s southern border, but not in all US States. Finally, in 1865, a little
more than 2 centuries after the first legalization of slavery, the 13th amendment was passed,
abolishing slavery throughout the whole country.
This kind of process for change also allowed for the legalization of gay marriage. The
first American gay rights organization started in 1924. From there, the movement gained support
18. throughout the years and in 1979, around 75,000 people gathered for a National March on
Washington for Lesbian and Gay Rights. In 2003, Massachusetts was the first state to legally
recognize gay marriage and now, thirteen years later, gay marriage is legal in all 50 states after
the Supreme Court ruling on June 28th, 2015. It may have taken almost a century, but the
necessary change eventually happened.
Obviously mechanical restraints isn’t the only problem impacted by a bureaucratic
system that needs solving right now. We can observe the dilemmas of bureaucracy in everyday
life. For example, standardized testing is still a major part of the college application process,
even though we know that standardized tests don’t actually measure one’s intelligence or
likelihood of success in college. Yet most colleges still require test scores for an application to
be considered.
Educational funding is primarily based off of property taxes which, in a country that
supposedly believes in people’s ability to succeed from hard work, and have equal opportunities,
sets poorer children behind wealthier children right from the very beginning.
People who are transgender, gender fluid, and even LGBTQ people face discrimination in
everyday life, even down to which bathroom they use.
Hopefully, like the issue of mechanical restraints, these other issues of human rights--and
fundamentally that’s what they are--can eventually become part of the past, like the enslavement
of African Americans, and the restriction of marriage to only heterosexual couples. It may not
be a very glamorous solution or even a satisfying one, but history has proven that it’s effective.
So if we can start by convincing individual states to revise or establish policies on the use of
mechanical restraints, then this issue, like slavery and gay marriage, could lead to national
change. The result then would be that people living with serious psychological conditions would
19. finally be safe from the harm and indignity that results from use of mechanical
restraints. Although this project has changed significantly from where it began, and although I
was unable to find ways to actually create the changes I was hoping to -- at least perhaps this is a
way forward.
Thank you.
