"We have techniques and technology to bring down a wild elephant without stress, yet when a fellow human being has lost touch with reality, we still think the best way of dealing with that person is to have six burly guys jump on him," Presas says. "We know what causes aggression. We don't seem to have an updated response to those situations. Instead, we keep addressing them in a way that is basically medieval."
The situation is not the result of a lack of good alternative options, says David Mandt, a Richardson businessman who created the "The Mandt System," an internationally recognized training program that focuses on de-escalation techniques. When he developed the system in the 1970s, Mandt says he based it on the principle that every patient has a right to be treated with dignity and respect.
"I thought, 'If my child was mentally retarded or had a developmental disability, how would I want him treated?'" Mandt says.
To Mandt, the problem with many of today's training programs is that while they may claim to address de-escalation techniques, they put too much emphasis on takedowns and cling to the idea that pain is a reasonable tool to use on unruly patients.
"We don't teach pain compliance. We don't teach takedowns," Mandt says. "The patient's natural reaction to that is to resist, and that's where most people get hurt. Once you're on the ground, everybody piles on."
In his experience, Mandt says, few patients are intent on causing injury when they become aggressive. But because of their illnesses, they can't effectively communicate their problems with mental health workers. So they act out.
"All behavior has meaning," Mandt says. "What we have to do is figure out what that behavior means."
To do that, Mandt says the first thing mental health workers must learn how to do is control their own behavior when tensions rise. Then, they need to learn how to stay relaxed so they can keep their patients relaxed. Everything they do, from their body posture to the tone of their voice, is an important part of the process.
Say, for example, a patient doesn't want to eat his dinner because it's hamburger and he doesn't like hamburger. Instead of asking why the patient isn't eating, workers will too often exert their authority over the patient, ordering him to eat or depriving him of dessert as punishment. It becomes a battle over who has control, and violence ensues.
"When do we empower people and allow them to make some of their own decisions?" Mandt says. "We're telling them when to get up, when to go to bed. The way we treat people sometimes, I don't know, it's just weird. People die over stupid stuff."
Peggy Perry is the assistant director of state mental health facilities at the Texas Department of Mental Health and Mental Retardation. She could not speak about Macie Stafford's case because of the litigation, but says the restraint-training program the state created in 1980 works well, though it has required some tinkering over the years.
"Early on there was some criticism that when people got through with training they were ready to go out and take somebody down," Perry says. "In recent years, there's been a lot more emphasis on prevention."
Today, all state employees who deal with patients have to complete annual "competency based" training, meaning that instead of just completing an exam they have to demonstrate that they can handle an emergency situation. When restraints are used for real, Perry says, the employees involved, their supervisor and the patients themselves together discuss what happened and how the situation can be avoided in the future.
Perry says the steps are working. In the first quarter of 1997, for example, the department recorded 5.75 seclusions per 1,000 bed dates. In the first quarter of 2001, that number had dropped to 1.4 per 1,000 bed dates. The number of restraints the agency recorded in the same time period also dropped, from 4.26 to 3.31.
For her part, Perry agrees that the unit rules at places like Terrell are sometimes restrictive, but she says the state has become more enlightened about the importance of relaxing them.
"In the past it was like, 'Take your meds!' Now it's like, 'OK, you don't have to do that right now,'" Perry says.
Advocacy's Presas, who spends much of his time interviewing clients at Terrell, says he has seen a decrease in the number of restraint-related injuries there, but he says Stafford's case shows the state still has a long way to go.