St. Elizabeths Hospital always had trouble with Tyler Johnson. In order to control their patient, who was there for psychiatric treatment, hospital staff repeatedly put him in one part of his unit and told him he couldn’t leave. There was a line on the floor: Don’t cross it. But sometimes he didn’t listen. That’s when the situation would escalate. According to incident reports obtained by the disability rights program at University Legal Services—an organization that monitors treatment quality at various hospitals in D.C. and advocates for disability rights—one time, Johnson “kept jumping back and forth across the line and was not receptive to staff directive.” So hospital staff made him go to a “seclusion room,” where he was locked up alone until they decided to release him. Another time, Johnson walked out of the area where he’d been told to stay put, and got into an argument with a staff member. They ordered him to walk himself to the seclusion room again, but he ignored that order too. So they put him in a physical hold and dragged him there. (The reports are anonymized; Tyler Johnson is not the patient’s real name.)

But the most extreme incident, ULS says, was when staff took Johnson down to the hospital’s “safety suite.” A barricaded room designed for long-term stays, the safety suite resembles a solitary confinement cell in a prison. The hospital kept Johnson locked alone in there for at least 20 consecutive days.

The District’s only public psychiatric hospital, St. Elizabeths has a long history of misusing seclusion (i.e. locking a patient alone in a room), a controversial practice that can cause severe, lasting psychiatric harm for patients. The hospital is operated by the Department of Behavioral Health (DBH), and in 2005, the U.S. Department of Justice (DOJ) filed a complaint against the city for using seclusion too liberally at St. Elizabeths and for violating patients’ constitutional rights. The lawsuit also charged that the hospital did not provide adequate treatment to its patients, and that environmental hazards at the (consequently rebuilt) facility put patients at serious risk. But after nearly a decade of major reform, St. Elizabeths improved its care enough to meet the requirements DOJ set out. The DOJ dropped the lawsuit in 2014.

But since 2014, the percentage of patients that St. Elizabeths puts in seclusion has gone up every year. And even more concerning, says ULS, the hospital recently started ignoring the laws that protect patients from unsafe seclusion, illegally keeping patients locked up alone for weeks on end.

Johnson is one of four patients who ULS discovered were recently locked alone in the hospital’s safety suite for far longer than the law permits—and those four patients do not include the people who spent time in St. Elizabeths’ other, official seclusion rooms. Two were kept in the safety suite for at least 20 days, one for at least 11, and the fourth patient spent at least 25 consecutive days locked up alone. The hospital may also have subjected more patients to long-term confinement without ULS finding out about it. Mark Chastang, St. Elizabeths’ CEO, tells City Paper, “The safety suite is an intensive therapeutic intervention that has been used to address consistent, violent behavior by six patients.”

“We are very, very concerned that this could potentially be very traumatizing to patients,” says ULS Staff Attorney Andrea Procaccino. “It’s so far from a therapeutic approach to treatment.”

It’s also illegal, says ULS. Both D.C. and federal laws impose strict restrictions on when and how psychiatric hospitals can lock patients alone in a room. Local and federal laws both mandate that seclusion can only be used in emergencies, for the minimum amount of time “necessary to prevent serious injury to the consumer or others.” But ULS says that St. Elizabeths has been keeping patients in “seclusion regardless of the patient’s current behavior, including [for] periods of time when the patient is calm and not dangerous.”

As soon as the patient no longer presents an imminent danger, by law, they must be released. In D.C., physicians cannot order seclusion for longer than four hours at a time, and staff must evaluate the patient every 15 minutes to see if they’re ready to be let free before then. If the patient hasn’t calmed down after the four hours, the physician can keep adding another four; however, no one can be kept in seclusion for more than 24 hours without a judge approving it first. Federal regulations add that “twenty-four hours of restraint or seclusion for the management of violent or self-destructive behavior is an extreme measure with the potential for serious harm to the patient.”

There is a reason these laws are so stringent—the damage solitary confinement causes people, especially those who already have serious mental illnesses, is widely documented. “It really traumatizes people,” explains Debbie Plotnick, vice president of the mental health advocacy group Mental Health America. If you spend a long time in seclusion, she says, “you may not have gone in with a severe mental health issue, but you can bet that you’re going to leave with one.” The lack of stimulation and human contact in seclusion rooms can have serious consequences. “That deprivation can exacerbate existing problems for people with psychosis. And it can cause psychosis in people who didn’t have it before,” she explains. “It’s antithetical to human functioning.”

But St. Elizabeths does not follow these laws when keeping patients in the safety suite, because it claims that the suite does not count as seclusion. D.C. law defines seclusion as “any involuntary confinement of a consumer alone in a room or an area from which the consumer is either physically prevented from leaving or from which the consumer is led to believe he or she cannot leave at will.” Federal regulations put forward a similar definition. But while the safety suite is a locked room that patients cannot leave, on May 23, 2018, St. Elizabeths issued a policy saying that putting patients in the safety suite is not considered seclusion. Instead, they call it a “general protective security measure.”

This refers to a vague exception in D.C.’s seclusion regulations, which were established by D.C.’s Department of Mental Health in 2005: “seclusion shall not include … general protective security measures including, without limitation, locked wards, or other special security measures.” (DMH was later merged with the District’s substance abuse agency to become the Department of Behavioral Health.) This means, for instance, that when the hospital locks the doors to a floor full of patients, that doesn’t count as seclusion. But St. Elizabeths has interpreted this clause liberally, using it to avoid any of the restrictions that govern how long they can keep patients alone in the safety suite.

“That is nonsense,” says Martha Knisley, who wrote the regulations that St. Elizabeths claims to be following. (Knisley was head of DMH when her agency wrote the District’s seclusion regulations, including the 24-hour limit on seclusion and the “general security measure” exception.) “A [locked] room is seclusion— that’s what seclusion is,” she emphasizes. “There’s no ambiguity there.”

Federal authorities echoed Knisley’s sentiment. A spokesperson for the Centers for Medicare and Medicaid Services, which handles the federal regulations, tells City Paper, “CMS is unable to identify any situation in which a patient is kept alone for long periods of time in a locked room that would not be considered seclusion.”

That May 23 policy goes on to say that patients may be placed in “flex cuffs” while they are being moved into seclusion or moved in and out of the safety suite. ULS attorneys also find this gravely concerning, because D.C. law explicitly forbids putting psychiatric patients in handcuffs. According to ULS, one patient was put in flex cuffs because the maintenance staff had to repair the safety suite’s locks. Another patient’s documents say that he should not be released from the suite until he has been well behaved for 20 days, including two days spent in “shackles.”

Knisley says that DMH began restricting seclusion in order to be “consistent with the reforms going on in the rest of the country” in the late ’90s and early aughts. One of the chief architects of those reforms was Charles Curie, who was head of the federal Substance Abuse and Mental Health Services Administration at the time.

Before he moved into national policy in 2001, Curie was in charge of Pennsylvania’s mental health system, where he managed to virtually eliminate the use of seclusion in all state hospitals. He tells City Paper he had realized not only that seclusion can cause serious harm to patients, but that in Pennsylvania, staff were often using seclusion “when there wasn’t any active treatment going on,” locking patients up instead of treating their illnesses. That’s when he decided to make it a priority to eliminate seclusion entirely.

A lot of people thought this was impossible, he says, and hospital staff were against it because many “felt that they needed to do [seclusion] for their own safety.” However, when hospitals stopped using seclusion, the number of staff injuries actually went down. Curie thinks this is because Pennsylvania increased the amount of “active treatment” that patients received, and also gave staff “extensive training on de-escalation.” In addition to improving staff training, he created bureaucratic rules to “make it inconvenient, frankly, for physicians to use seclusion.” Pennsylvania never banned the practice. Instead, he says, it redefined “seclusion and restraint not as treatment interventions, but as treatment failures.”

Additionally, “one thing that was critical for us was to make sure we had adequate staffing levels,” says Curie. “Staff may turn to seclusion if they feel they don’t have enough support to do their job.”

St. Elizabeths has successfully made similar reforms in the past, albeit at a smaller scale. When the U.S. Department of Justice investigated the conditions at St. Elizabeths in 2005 and filed a lawsuit against the city for violating patients’ constitutional rights, one of the chief issues in the lawsuit was the hospital’s use of seclusion and restraint. (Restraint refers to any measure that physically restricts a patient’s freedom of movement.) Federal investigators found that staff were often using the practices inappropriately, in ways that were “clinically inexplicable” and “substantially depart from generally accepted professional standards.” In one instance, investigators said, a patient attempted suicide; in response, staff members just tied her arms and legs to her bed for 24 hours. Four days later, she attempted suicide again.

As part of the eventual settlement, DOJ required that St. Elizabeths substantially reform the way it used seclusion and restraint, including training all its staff on “less restrictive interventions.” It took almost a decade of hard work for the city to successfully implement all the reforms that DOJ asked for. But in 2014, the feds decided that St. Elizabeths had come into compliance with federal law and dismissed the lawsuit—with the stipulation that the city continue to let ULS monitor conditions at the hospital.

Over the past five years, the rates of seclusion and restraint at St. Elizabeths have gone up astronomically. The hospital is required by law to report how often it uses these extreme measures. (However, since it does not consider the safety suite to be seclusion, there is no data on how often the suite is used.) According to St. Elizabeths’ monthly performance reports, the number of patients locked in rooms it does consider seclusion has more than doubled since 2014, when 2.55 percent of patients were locked in seclusion in any given month. In 2018, 5.9 percent of patients were placed in seclusion.

The change is even more dramatic when it comes to the use of restraints. In 2014, an average of just 0.5 percent of patients were placed in restraints in any given month. In 2018, 13.06 percent of patients were restrained each month, more than 25 times as many patients as in the year the lawsuit ended. The average number of hours patients spent in restraints also increased by more than 1000 percent over this period. Saint Elizabeths and DBH did not respond to City Paper’s request for comment on these increases, nor on whether the hospital or the agency is taking any steps to address them.

Procaccino and Curie both pointed to inadequate de-escalation training as a factor that often leads to high rates of seclusion and restraint. “If the de-escalation is done correctly, [St. Elizabeths] should have no reason to put people in these rooms,” explains Procaccino. “We don’t think there’s enough implementation of de-escalation techniques.”

In January, ULS sent a report about the safety suite to DBH and to DC Heath (which recently changed its name from Department of Health, or DOH), at which point both agencies told ULS they would investigate. According to Procaccino, both investigations are pending. “I was hoping that DOH would come back by now saying they have to shut [the safety suite] down,” says Procaccino. “I’m surprised they haven’t closed it.”

But it appears that the DC Health investigation just concluded that ULS is correct, at least with regards to the federal law. Eight days after City Paper reached out to DBH and DC Health for comment, Chastang replied via email. “DC Health has determined that federal seclusion regulations regarding timely monitoring apply to the safety suite,” he wrote. “Saint Elizabeths is revising its policies and procedures to comply.”

ULS attorneys hope that St. Elizabeths will stop using the safety suite entirely. “It should never be necessary to expose any patient to a prison-like solitary confinement room,” wrote ULS in the report it sent to DBH and DC Health. “Locking patients in a solitary confinement seclusion room is not only illegal, it is traumatic and damaging to a patient’s recovery.”

“St. Elizabeths hospital is not a prison,” the report continues. “It is a psychiatric facility responsible for providing treatment to the patients entrusted to its care.”