An increased regulatory focus on removing psychiatric inpatients’ opportunities for self-harm has led Vermont’s hospitals to make major changes to improve safety. But according to psychiatric survivors, some of these changes have yielded unintended consequences in how supportive the units feel.
The Centers for Medicare and Medicaid Services defines a “ligature risk” as “anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation.”
Possible ligature points, per CMS, include “shower rails, coat hooks, pipes, and radiators,” among other common objects.
Hospitals offering psychiatric care can achieve regulatory compliance by removing such objects or, when removal may not be possible, by restricting patient access to spaces that contain them.
By some accounts, this effort has had the side effect of creating a less hospitable and less free environment in psychiatric units.
After several earlier stays, a psychiatric inpatient returned this fall to Central Vermont Medical Center. She noticed a number of differences. In the past, by her recollection, patients had enjoyed unsupervised use of the laundry facilities.
Now, they had to ask staff to unlock the laundry room each time they wanted to wash, dry, or retrieve their clothes.
The same locked area of the psychiatric unit also contained books, puzzles, and an exercise bike, as well as a small, semi-enclosed terrace that patients used to be able to visit as they pleased.
Now, however, staff had to bring books out to them, and the terrace was off-limits all day except for an hour, during which patients would crowd together for a few breaths of fresh air as staff looked on. The unit’s microwave had also disappeared, and patients had lost access to hot water for tea.
Under CMS rules, hospital patients have “the right to receive care in a safe environment.” The agency’s interpretive guidelines specify that this requirement intends to protect “the patient’s emotional health and safety as well as his/her physical safety.” Sometimes, however, these paired promises appear to come into conflict with one another.
“How can you feel comfortable enough to start healing if you feel that you can’t do things for yourself, and you have to feel you’re bothering someone to do something simple?” the CVMC patient asked.
Understaffing had compounded the problem. Overburdened workers could still be “pretty accommodating if people were patient,” but the patient also reported an instance in which one staffer became “very annoyed” by a request for assistance. An encounter of this kind “really impacts the way you feel about yourself,” the patient said.
Hospital officials attributed most of the changes experienced by the Central Vermont Medical Center patient directly to new ligature risk requirements. They pointed to stricter inspections by surveyors from the Joint Commission, the organization that accredits US hospitals. In 2019, the Joint Commission revised its “national patient safety goals” for suicide prevention, following a 2017 decision by CMS to prioritize ligature risk within its own regulatory framework.
“There were reports of increased amounts of inpatient deaths on psychiatric units,” Dr. Robert Althoff, the chair of psychiatry at the University of Vermont Health Network, recalled. “That then translated into surveys that specifically looked at what are opportunities on inpatient psychiatric units for people to hurt themselves.”
Althoff mentioned that the University of Vermont Medical Center had needed to buy new, safer beds for inpatient psychiatry, in addition to addressing smaller items like door handles and shower bars.
Those beds, which replaced previously approved “psych-safe” beds, are single piece plastic molded units with a mattress on top. UVMMC solicited input from its patient advisory committee in its attempt to select ones that felt least institutional.
“Any flat surface had to have something that was diagonal, so that a ligature would slide off of it rather than wrap around it,” he recounted. “Things that may have met the standard 10 years ago now don’t meet the standards.”
“I can imagine, having talked to people, that it would feel like it’s a more sterile environment – that it’s just a plainer environment than you would want, that it could not feel as friendly,” Althoff acknowledged.
Dr. Conor Carpenter, the medical director for inpatient psychiatry at CVMC, told a similar story about the Joint Commission surveys.
“Their reviewers are not unaware that things that they may ask in terms of creating safe environments have a trade-off for a therapeutic environment. Yet they make it clear that their priority is in safety, and we do the best we can to work with that and maintain as therapeutic an environment as we can here,” he said.
New ligature safety standards aren’t the only changes that have taken place in psychiatric units over the years. Since 2020, COVID-19 precautions have periodically limited visitors and, at times, confined patients to plastic “anterooms.” Before that, health and sanitation standards had already evolved, such as favoring surfaces that don’t allow liquids to soak in.
“You don’t want rugs because they collect pathogens or whatever you want to call it,” said a former UVMMC inpatient, whose most recent stay, in 2020, brought back memories of a “dramatically more homey” environment at the same hospital during earlier hospitalizations between 1999 and 2004, with comfortable couches and available snacks.
“If you restrict food, you’re less likely to have food scattered around, so you’re not going to have germs from this food that gets spilled,” he elaborated. “It’s a progression, I think, that’s been happening for a while.”
A patient who had been hospitalized at CVMC in the 1980s found herself at the same facility again this August. In the old days, she had passed the time by making mosaic tile hot plates and had sometimes received permission to leave the hospital temporarily.
But this year, she found no arts-and-crafts program inside the psychiatric unit, which she couldn’t exit until her discharge.
Two patient representatives at Vermont Psychiatric Survivors, Grace Walter and Laura Shanks, relayed comparable anecdotes from clients in inpatient settings.
Walter described a Vermont Psychiatric Care Hospital patient who “has been in the psychiatric system for a long time” and “enjoyed collecting leaves or flowers and hanging them on his walls or door” after time in the yard. More recently, however, the patient was “told he wasn’t allowed.”
Shanks brought up an inpatient at UVMMC who, at the start of her third stay this year at the facility, discovered suddenly that she would not be able to bring her wedding band or other small personal items that “provide therapeutic support” into the psychiatric unit with her.
“It didn’t make sense. To me, those don’t pose a risk of harm,” Shanks said.
A third VPS patient representative, Nate Lulek, offered a happier picture of Rutland Regional Medical Center, which, starting in 2019, spent more than $4 million to redesign its psychiatric unit to “correct risks of self-harm.”
Lulek’s account suggested that, by reconstructing the unit from top to bottom, RRMC had managed to provide ligature safeguards without adding restrictions upon patient movement, resulting in few complaints.
He also praised efforts to offset the sterility of the ligature-resistant environment.
“They had artists go up and do murals in common areas. Each one of the rooms are single, and they have artwork from local artists, so that it gives it less of an institutional feel, to a certain extent.”
A patient comment supported what Lulek said. “When I was in RRMC in August 2021, it was not oppressive, but freeing, and health restoring,” she said.
But Lulek noted in November that RRMC was due for a survey by the Joint Commission, which must reaccredit hospitals every three years.
“RRMC got notified, I think, last month,” he said. “And who knows if there’s going to be any more stuff thrown on that now has to be done?”
A 2019 report by the National Association for Behavioral Healthcare estimated that, nationwide, hospitals had to spend $880 million annually in order to comply with ligature risk regulations that could be “unpredictable” and “inconsistent.” The report recommended reforms such as “a more evidence-based approach to ligature-risk review,” whereby regulators would not demand modifications without “a compelling empirical basis.”
According to NABH President Shawn Coughlin, the report made an impact.
“We were able, in working with CMS, to get some clarifications and some standardization that we had hoped for,” he said.
But that doesn’t mean that Joint Commission surveyors have necessarily altered their judgments yet.
“It absolutely does take time to filter down through the various survey processes, and there probably will always continue to be various interpretations by surveyors,” Coughlin surmised. “Obviously, we’d like to see them be in lockstep.”
In 2018, an article in the Joint Commission Journal on Quality and Patient Safety debunked the commonly cited statistic that the United States sees 1,500 inpatient suicides annually. In fact, the researchers found that the number was closer to 50 or 60.
“There’s so few incidences of people committing suicide in hospitals,” a patient told Counterpoint. “We’re spending a lot of money to avoid a very, very rare event. And that’s money that could otherwise have been spent someplace else and could have affected lives and reduced suicides in a different way.”
In 2018, Counterpoint reported on a change at the Brattleboro Retreat that required bathrooms to be locked, meaning that patients had to find a staff person to unlock one any time they needed to use the facilities.
The Retreat attributed the change to its own assessment of safety needs, and said there were no alternative measures that would keep patients safe.
“Being denied autonomy over one’s basic bodily functions – being made to ask permission to relieve oneself – is… demeaning and humiliating…” said Calvin Moen, a patient representative from Vermont Psychiatric Survivors at that time.
VPS called it an “affront to patient dignity” and said that patients found it “dehumanizing and degrading.” The Retreat did not respond to requests by Counterpoint for comments for the current article.
Editor’s note: psychiatric survivors interviewed for this story asked not to be identified by name to protect their privacy.