Justice for people with disabilities - struggles over restraint use and the role of public health

Since 1972 courts have found the arbitrary use of mechanical restraints in public psychiatric hospitals to violate the constitutional right to liberty, but the rulings have had little impact. Subsequent research examined long-standing staff assumptions that restraints prevented harm and were therapeutic. The studies found that restraint use in these settings produce alarming rates of psychological trauma, serious injury and death, and that restraint usage correlates with staff attitudes about coercion but not with clinical factors. As the evidence mounted, some farsighted facility leaders took action. While recognizing that the intervention may be unavoidable in rare instances, these administrators created inexpensive, replicable programs which dramatically reduced restraint use. These programs, though well-documented in the literature, have not been widely implemented in the public mental health system. The continuing use of restraints in many facilities raises grave concerns about iatrogenic harms and deprivations of dignity experienced by marginalized citizens. It also raises policy issues as to the delays incorporating significant research findings into disability services, and as to differences in the attention paid by the public health community to restraint use in nursing homes and psychiatric facilities. The discussion will identify tools for public health practitioners to assess services for people with disabilities which are assumed to be appropriate but may not be. Using the extreme example of restraint use, the paper will suggest strategies developed in the field of disability studies that can be useful in making social justice a public health imperative.