The Minnesota Security Hospital is located in St. Peter, Minn. Courtesy Department of Human Services

Three years have passed since the Minnesota Security Hospital was put on a conditional license for the overuse of seclusion and restraint, but staff and state administrators are still at odds over how to control aggressive behavior.

The Minnesota Department of Human Services runs the St. Peter facility, which houses 373 of the most violent and mentally ill patients in the state. The department's licensing division has kept a close eye on the hospital since 2011, when it found staff was putting patients in restraint and seclusion for hundreds of hours, even in nonemergency situations.

A recent assault that landed a security counselor in the hospital with severe head injuries has rekindled the controversy surrounding the use of restraints. The American Federation of State, County and Municipal Employees (AFSCME) union Local 404, which represents security hospital employees, is demanding a freer hand in the use of such measures.

AFSCME spokesperson Jennifer Munt said mobile restraints — padded leather cuffs attached to a belt around a patient's waist to prevent swinging arms and legs from hitting staff and other patients — should be used when patients exhibit violent behavior.

"We're now told that we can use the [restraint] chair but we cannot use the padded cuffs," she said, adding: "What the law permits and what's actually being implemented is inconsistent."

DHS policy clearly lists mobile restraints, along with a number of other mechanical restraints, as a tool to keep patients from hurting others and themselves.

The policy allows use of restraints in self-defense, not for punishment. Common security hospital practices in the past allowed for the use of mobile restraints while patients were in protective isolation for weeks and months at a time.

"What some of our staff are wondering is if we can return to the previous practice in which mobile restraints were used for long periods of time in the absence of imminent risk," said Steven Pratt, executive medical director for behavioral health at DHS, who oversees the security hospital.

Minnesota Security Hospital employees also may use seclusion when patients become physically violent. Staff may isolate patients in a room until they calm down.

Although the amount of time patients spend in restraint or seclusion has dropped dramatically since policies changed in 2012, the practice hasn't been eliminated. DHS data from 2012 through May of this year show that seclusion and restraint periods, measured in hours, increase in the fall months from September to November and drop the rest of the year.

"What we are finding is that the use of seclusion and restraint has fluctuated within a limited range," said Pamela Hoopes, legal director of the Minnesota Disability Law Center, who's reviewed data on restraint and seclusion. "One thing we are finding is that a small minority of patients seem to account for most, numerically speaking, of the restraint and seclusion incidents."

The Minnesota Security Hospital has four separate units, with the majority of patients living in a secured setting. A small number of patients are committed only as developmentally disabled, not as mentally ill. Staff cannot use any sort of mechanical restraints on those patients.

But some of the patients have both mental illness and developmental disabilities, adding a confusing element to the policy, Hoopes said.

"I think one of the things that concerns us and others is that a uniform policy governing the use of restraint and seclusion and the application of positive treatment interventions should really apply to all of the patients at the security hospital regardless of their disability," she said.

Mental health advocates say that regardless of the policies, restraint and seclusion should never be used unless there is a clear, imminent risk of harm. That such measures are used at all, they say, is a treatment failure suggesting that psychiatrists and counselors aren't getting to the underlying illnesses that cause aggressive behavior in the first place.

Sheila Novak, mother of a mentally ill patient who's lived at the St. Peter facility more than four years, said things are improving and that staff training, policy changes and legislative action have made a difference.

But it will take time to change the culture from a correctional-facility type of housing to a therapeutic environment.

"In the past, security outweighed the treatment," Novak said. "If people are being treated for their mental illness, some of these behaviors that we're seeing may not be as prevalent."

Novak sits on the Partners on Care Advisory Council, which DHS formed this year to come up with ways to improve the security hospital's operations. The group includes department heads, security staff and families of patients.

Novak said recent training and staff changes have improved the overall attitude of the staff and her son's condition. Bringing back restraints would be counter-productive, she said.

"That seems to be going backwards in my opinion," she said. "We need to learn better ways of handling these situations."

But aggression-related staff injuries have increased since restrictions were imposed on the use of mobile restraints, AFSCME officials said. OSHA reported 68 injuries in the first six months of this year, a number union officials called unprecedented.

"We're told that you can only put hands on a patient if you feel that you're in imminent danger," said Munt, the AFSCME spokesperson. "Well, imminent danger is subjective and management would need to trust our judgment in order to make that work."

According to a licensing review this year by DHS, Minnesota Security Hospital staff failed to follow policies that require talking a patient through changing his or her behavior in order to be released from restraint and seclusion. Three of the seven resident files reviewed showed staff violated the policy, according to information released this month.

Human Services Commissioner Lucinda Jesson said all the staff currently working at the security hospital have been trained, but she acknowledged that additional training is necessary. She said it is difficult to write a clear policy that spells out every specific situation in which the use of restraint and seclusion is justified.

The department still needs to train security hospital staff in exactly "what is imminent risk of harm," Jesson said. "We've started that, but that's a work in progress."

Over the past year, DHS has hired a new medical director, two psychiatrists and two advanced-practice psychiatric nurses. The department has vowed to fill 20 security counselor positions. But AFSCME officials say they have 54 security counselor vacancies that, if filled, would help reduce the number of staff injuries.

Tim Headlee, a security counselor and president of AFSCME Local 404, said it usually takes five employees to physically restrain an aggressive patient. Over the past three years, the staff has recognized what's working and what's not, he said.

"And at this point in time, dealing with this type of [violent] client, we feel that what we're doing isn't working," Headlee said. He said union members are hoping that they'll be allowed more latitude on mobile restraints "in hopes that we can use them until either someone comes up with a better idea or we have something that's effective."