Fairness During Group Games Treatment Facilities

 Fairness 

When playing group games in mental health and developmental disabilities treatment programs, the games are often improper or unfair. 

This is not as big an issue at the State Hospitals for adults, but it is more of an issue at day programs and private short-term care hospitals for adults. For children and adolescents, fairness is a vicious problem across the continuum of care.  

First off, staff should never be allowed to compete against or alongside service recipients, and staff vs. service recipient tournaments should be prohibited. It can be a safety issue when playing physical games, such as kickball, as a bad kick or throw from staff could cause injury to the service recipient. When staff participate in cognitive games, it can imbalance the ability level of each team due to cognitive deficits as a result of developmental disorders, mental illness, or the medications used to treat them.  

Staff should give everyone an equal opportunity to win. For instance, staff should not help one service recipient find a number on a bingo board and not provide the same assistance to others who ask for it. 

Teams should be divided equally by the number of players and ability levels, and never based on clinical criteria such as commitment status, diagnosis, or level of functioning. When this happens, it perpetuates stigma throughout the system of care that individuals with more severe diagnoses are not capable of winning a game, especially when medication impacts their participation. 

It is fitting that unfair games can contribute to resentment and deep-seated anger towards the entire field of psychiatry, which can cause other problems, such as high restraint and seclusion rates (for children, adolescents, and adults) and low treatment retention rates (especially for adults), among many problems that could potentially result from these feelings. 

First off, we need to assess the root cause of the problems associated with fairness. Then we have to fool around with solutions that might resolve the problems. After that, we need to create regulations that support those solutions.  

The State and the federal government need to design financial incentives for having fair games in treatment facilities. We need to research how unfair games impact the treatment of different types of service recipients.  A lot of service recipients will not make complaints about this because they think it is “too trivial” a complaint. Service recipients should have the right to fair games. It is just not therapeutic to have unfair games in the mental health and developmental disabilities treatment programs.

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9 Reasons Why We Need Facility-Based Residential Programs

 We need facility-based residential  programs for individuals with dual diagnosis because: 

1. Those with dual diagnosis with severe challenging behavior are not usually welcome in group homes. 

2. When residents display challenging behavior, staff often call 911, and the police are often summoned and bring the resident to the hospital. In a facility, staff from other units may be called to help deal with the crisis. 

3. Facilities offer more stimulation for service recipients who thrive on activity and “noise” 

4. Facilities have the infrastructure to use mechanical restraints, personal control techniques, and hands-on behavior management techniques. Group homes are very hesitant to use these strategies and only use them after 911 has been called. Facilities avoid calling 911. 

5. Facilities reduce the waitlist for residential services since there are more beds in facilities than in group homes. 

6. Facility-based programs allow families to have choices for residential care. 

7. A facility offers more structure than a group home, and some people need structure only for the support found in a facility-based program. Daily schedules and activities are a hallmark of programming in a facility, and group homes are less structured. 

8. Some people need more skills training than is available in a group home. A facility offers more opportunities for skills training in a controlled environment. 

9. Group homes do not work for everyone!!! 

We need more campus programs and dormitory-style large buildings with locked units to serve the most difficult service recipients with dual diagnoses. 

Note that I don’t use the term “institution” to describe these programs, as that term is very reminiscent of the 1980s, when there were "real" institutions. 

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My Deluxe Holiday Post

 Happy holidays, readers!

This is my deluxe holiday post.

 

The December holidays are an extremely difficult time of year for a variety of people for many reasons. I asked the participants of a group therapy session, “What is the most stressful part of the holiday season?” For privacy reasons, I do not share their names, but these are their responses:

• Loneliness

• Missing family, family far away

• Memories of loss, death, and trauma 

• Worrying about the finances with the gifts

• Planning and budgeting

• Overwhelming feelings

• Cooking and expectations of good meals 

• Family conflicts 

• Seasonal Affective Disorder 

• Lose sight of the religious aspects of the holidays.

• Commercialism

• Weight gain

Remember, not everyone is going to have the “fairy tale” holiday season. Make it your version of ideal, and be flexible in your definition of a good holiday.

Feel free to seek professional help or therapy to make this time of year easier and more festive, if you feel you need it.

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Continuing Care Residential Facility

 I believe we need a non-institutional residential facility designed similarly to a continuing care retirement community with various levels of care that individuals may move through as their needs change; yet, continue to remain with the same treatment team, recommendations, diagnostic assessment, and a familiar environment for those with Autism and/or mental illness and challenging behavior. This type of facility should be run by a nonprofit provider agency or hospital network, not the State, to prevent it from becoming an “institution”. 

Levels of care at this type of facility should include: 

• Forensic Care Units: designed similarly to a therapeutic correctional facility for those with criminal charges
• Intensive Care Units: designed similarly to a forensic facility but with more of a focus on rapid tranquilization using antipsychotic medications and behavior modification, for those with extremely chronic, dangerous behaviors and who fail or get "kicked out" of less restrictive programs
• Inpatient and/or Dormitory Units: service recipients live in a large building with locked and unlocked units 
• Campus Residences: individuals live on a large piece of land in cottages or small dormitories 
• Supervised Apartments: service recipients live in individual apartments with 24-hour staff in a large disability-only apartment complex

This type of facility will increase continuity of care, as the same treatment providers will possibly follow service recipients throughout their time at the facility. It is intended for long-term, lifelong placement, and the individual will receive "Active Treatment." It should not be restricted to those with an IQ under 70, and higher-functioning and lower-functioning service recipients will be admitted to different sections of the facility to allow for appropriate treatment. 

Funding streams may come from the State developmental disabilities agency (possibly as an Intermediate Care Facility for Intellectual Disabilities [ICF/ID]), mental health agency (possibly through its own funds as Medicaid will not fund a psychiatric facility larger than 16 beds), Medicaid (possibly as an Intermediate Care Facility for Intellectual Disabilities [ICF/ID] or Skilled Nursing Facility [SNF]), and more. 

This will be ideal for those who do not succeed in group homes because of their behavior. However, we do not want to make this a prerequisite for admission to a continuing care facility like this. We do not want to wait until someone fails before considering them for a facility like this. 

When the individual receives treatment aimed at reducing challenging behaviors, their challenging behaviors may decrease, and they may move to a lower level of care within the facility. Yet, when there is a crisis or escalation of challenging behavior, they can easily move to a higher level of care without going to the hospital and without police intervention. 

This type of facility will also be ideal for those with primary mental illness (standalone or with a developmental disability) who are discharge resistant or who face significant barriers to discharge due to chronic higher-acuity behaviors, as an alternative to a State institution. Oftentimes, psychiatric hospitals and units only stabilize medications (not provide behavior modification). They only provide acute care, and these individuals have chronic behavioral problems. A facility like this could help supplement the care given in a psychiatric hospital or unit when a State Hospital is not appropriate, including for forensic service recipients. It is widely known that short-term psychiatric hospitalization only causes more disruptions in the lives of those with Autism or severe mental health challenges, and it is also known that short-term psychiatric hospitalization may reinforce the challenging behaviors that led to it. As of yet, there are no better alternatives. 

This type of continuing care facility is an alternative to resolve all these problems.

My Official Views on the Use, Misuse, and Abuse of Restraints and Seclusion

Just posting this because there seems to be confusion about my views on restraints and seclusion. I am opposed to restraints and seclusion when it is not needed. However, when there is a clear and imminent danger to the service recipient or others, I highly support restraints and seclusion as a lifesaving measure, just like CPR for cardiac arrest. The commonality between CPR and restraints is that they are only used when necessary and all else fails, and are avoided when safe to do so 

While restraint and seclusion are not ideal, they cannot be eliminated. However, they can be reduced by changing the culture in our facilities. When done appropriately, safely, and correctly, they can be lifesaving interventions. 

For instance, if someone is banging their head and staff cannot stop them from doing so, they could go blind from detaching their retinas or suffer seizures or death from the neurological consequences of the behavior. 

We need more trauma-informed care and safe and therapeutic crisis intervention. 

Some service recipients find restraints and seclusion soothing. We need to teach these individuals other coping mechanisms that are more adaptive in the community that meet the same needs that restraints and seclusion are meeting. 

We need to track and trend antecedents to these adverse events on a weekly, monthly, quarterly, and annual basis. 

In my experience, nurses will restrain or seclude individuals they dislike more than those they like. Also, service recipients who “cause trouble” will be restrained or secluded for excessive periods.  Nurses and staff sometimes purposefully escalate a crisis, so they have an excuse to use restraints and/or seclusion. This is unacceptable, inappropriate, and should be considered abuse. 

Nurses should not be allowed to combine seclusion and restraints by locking the door to a room where someone is restrained and having staff watch them via a surveillance camera. This is unsafe, inappropriate, and potentially frightening for the restrained individual. 

Until we wholeheartedly adopt the philosophies of psychiatric rehab, trauma-informed care, and person-centered treatment, we will continue to rely on restraints and seclusions. We need to try a different approach to crisis intervention, one that we are not used to. This is the only path to reducing and eliminating restraints and seclusion. 

Restraints do not teach anyone new skills, and they are little more than a punishment for bad behavior. 

Restraints and seclusion are traumatizing, both emotionally and physically. Service recipients can sustain serious physical injuries when restraints are used improperly, sometimes worse than the behavior that prompted restraints. 

Nurses need to take the time to listen to service recipients about their thoughts and feelings regarding the incident. Restraints are especially harmful when the service recipients do not know why restraints or seclusion were used, and what to do next time to avoid a similar situation. 

Centers for Medicare and Medicaid Services (CMS), The Joint Commission, CARF, and other accrediting bodies need to weigh in on the abuse and misuse of restraints and seclusion. 

We need crisis teams comprised of peer specialists, nurses, psychologists, psychiatrists, therapists, and therapeutic security officers to help de-escalate crises, hopefully without restraints or seclusion. More peer support specialists are needed at a higher or equivalent ratio to the direct care staff. 

In conclusion, restraints and seclusion should be a last resort intervention in a dangerous crisis. They should be thought of as a “treatment failure” rather than a “treatment intervention”; however, when needed, they should be available. It’s a tricky balance. 

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The Moderate Security Unit at New Jersey's New Lisbon Developmental Center

II am posting this in light of Ombudsman Paul Aronsohn's 2024 report, which was released in July 2025 and highlights the need to reassess the use of the Moderate Security Unit at the New Lisbon Developmental Center for individuals with developmental disabilities and criminal charges. A variation of this post, which I authored as an opinion piece, was published in the lBurlington County Times several years ago. 

We need to change NJAC 10:42B and the resulting Division of Developmental Disabilities Division Circular #16 to  allow females and those with a severe IDD/MI psychiatric diagnosis  to be admitted to the Moderate Security Unit  at New Lisbon Developmental Center  

 I believe the Moderate Security Unit at New Lisbon Developmental Center (MSU) needs several modifications admissions criteria to meet current demands.  The MSU is a secure-care unit for developmentally disabled men who would not be safe in prison or jail, due to their disabilities.

The admissions criteria should be expanded to females and those with a severe psychiatric disorder, including those found Not Guilty by Reason of Insanity, because:

• Psychiatric facilities, such as the Trenton Psychiatric Hospital and Ann Klein Forensic Center, are not necessarily the appropriate setting, since individuals may get victimized and do not receive specialized developmental treatment.

• Placing individuals who have committed a criminal at in a regular Development Center poses a risk for lower-functioning individuals, who are more vulnerable.,

• Most reasonable people would agree that individuals with developmental disabilities do not belong in traditional correctional facilities (i.e., jails and prisons) for a variety of safety reasons (especially abuse by corrections officers and other inmates)

There will need to be several changes to the physical plant, staffing patterns, and programs to make the MSU suitable for females and those with a severe psychiatric disorder:

• Female staff are needed.

•  Hiring uniformed medical security officers, similar to Ann Klein Forensic Center, could help maintain control of the unit (research shows that a police-like uniform deters negative behavior and makes people feel safer)

• Toilets in each bedroom

•  Steel doors instead of bars (to prevent ligature)

• Males and females are admitted to separate sides of the unit.

• Surveillance cameras need to be installed to prevent abuse, neglect, and exploitation.

•  Seclusion (residents would be locked in their rooms alone for set times during the day, at night, during short-staffed times, during crisis situations, etc., and when the resident is displaying aggressive behavior and failing to calm down)

• Chemical restraints should continue to be emphasized over mechanical restraints in emergency crisis situations.

• Therapeutic programming should be modified to provide treatment aimed at reducing the likelihood of a re-offense for a variety of criminal offenses, not just sexual and arson crimes.

  
  

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Sensory-Friendly Transportation

 I believe we need to provide those with Autism with the option of using sensory-friendly public transportation when they cannot tolerate a bus or train for sensory reasons. This would allow them to access small group rides in a car, minibus, or minivan rather than a traditional public bus or train. This is not medical transportation, and it could be used to get to work, family, and community activities, not just medical appointments. 

I believe we need to expand upon the idea of using Uber as a transportation provider, which will help to provide special transportation services for those with Autism so that no one with Autism has to arrive at their destination in sensory overload (which a bus or train could produce).

In New Jersey, I suggest that NJ Transit Access Link expand its criteria to include those with Autism who cannot tolerate a bus or train for sensory reasons.

The New Jersey Division of Developmental Disabilities (NJ DDD), ModivCare, LogistiCare, and Medicaid need to collaborate to create this type of transportation.

While many group homes have transportation through house vans, this is simply not enough to get everyone to their desired destinations. There are not enough vans and staff drivers to get everyone where they need to be at the right time. Some individuals are forced to use public transport, which again should not be the only option.

NJ DDD needs to consider providing individuals receiving transportation services out-of-state rides, so they can see far away friends and family. 

NJ-supported employment programs need to provide sensory-friendly transportation so individuals can get to work, even when they cannot tolerate a bus or train.

While some people with Autism do just fine on a bus or train, we need other options for those who have difficulty with traditional public transportation.

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Wheelchairs are Not Restraint Chairs on Wheels

Sometimes, traditional wheelchairs are used as restraint chairs on wheels to move uncooperative service recipients from place to place. This can be deadly. 

In my experience, I was physically held in a wheelchair to be moved from unit to unit when I refused the transfer. From the struggle that occurred during the incident, I ended up on the floor underneath the wheelchair in a position where my diaphragm could not easily expand and breathing was difficult. This can cause positional asphyxia and people can die this way. 

I also witnessed staff strap a child into a wheelchair with restraints and move them to the Quiet Room. As a result of the struggle that ensued, the child ended up in an upside-down position with the restraints wrapped around the child’s neck. This can cause strangulation. 

Rather than using makeshift restraints (I.e. Traditional wheelchairs), we need to purchase “real” restraint chairs with wheels and use safe and appropriate ways of moving uncooperative service recipients from place to place. 

Autism Therapies

 Other Autism Therapies

There is a plethora of therapies and treatment models available for those with Autism Spectrum Disorder, other than Applied Behavior Analysis (ABA) and Positive behavioral support (PBS), to be used in conjunction with and separate from ABA and PBS, which are just as effective or more effective than ABA and PBS.

Treatments include:

1. the Alert program (the How's my Engine Running program)
2. the Zones of Regulation and Social Thinking curriculum
3. Son-Rise program
4. Animal Assisted Psychotherapy or Pet Therapy
5. Equine Assisted Psychotherapy and Therapeutic Horseback Riding
6. Social Stories
7. Comic Strip Conversations
8. SELF (Safety, Emotions, Loss, and Future) model
9. WRAP (Wellness Recovery Action Plan)
10. Dialectical Behavior Therapy for Special Populations (DBT-SP)
11. The Emotion Regulation Skills System for Cognitively Challenged Clients
12. ESCAPE-Now curriculum
13. Circles program
14. Collaborative Problem Solving model
15. Motivational Interviewing
16. Supportive Humanistic Psychotherapy
17. Trauma Informed Care
18. Cognitive Behavior Therapy (CBT)
19. Trauma-Focused Cognitive Behavior Therapy (TF-CBT)
20. Exposure Response Prevention (E/RP)
21. Psychopharmacological Intervention
22. The TEACCH approach 

Again, we need to not only provide but also promote other therapies in addition to ABA and PBS. Everyone is unique and ABA and PBS do not work for all individuals with Autism. It is not a one-size-fits-all situation. 

Nursing Homes

 

Please be advised that use the term “LTCF” in place of “Skilled Nursing Facility”. 

I believe we should expand the criteria for nursing home level of care (long-term care facilities – “LTCFs”) to those with mental illness, who are too symptomatic to live in a community group home and/or supportive housing living arrangement, regardless of whether or not they have medical problems and/or self-care deficits.  Oftentimes, people with severe mental illnesses are housed in State Hospitals or keep returning to Emergency Rooms or correctional facilities through the revolving doors, seeking treatment of a longer duration than is available in regular short term psychiatric facilities.

With many States privatizing their State Hospitals, it is safe to predict that at least some of these individuals will be left to fend for themselves in a dangerous world. Many hospitals will discharge individuals to a homeless shelter. This is not ideal whatsoever. Homelessness is a big problem for those with mental illness and having a continuum of housing options, including more restrictive options, such as LTCFs, would be a better solution. 

In LTCFs, there is the infrastructure to have various rehab programs, run by a full treatment team, including nurses, direct care staff, medical security officers, psychiatrists, psychologists, behavior analysts, medical doctors, family specialists, social workers, counselors, dieticians, and peer support specialists. In other settings, these programs and the full treatment team may not be readily available.

Letting people go around hurting themselves and/or others without professional intervention in a safe setting is a violation of everyone’s right to a safe environment. In LTCFs, there is more external control for those with a high suicide and/or violence risk and who lack internal impulse control. In a group home or supported housing, you can just walk out and hurt someone. In an LTCF, the doors are usually locked, and you need supervision to leave. Also, LTCFs may have the full repertoire of restraints and seclusion, including physical holds, seclusion, mechanical restraints, and chemical restraints. Having a setting with a full repertoire of restraints and seclusion is ideal for those who continue to need these interventions for dangerous behavior. Calling 911 or 988 will not suffice as individuals may be arrested or brought to the Emergency Room, which results in very expensive jail and hospital admissions. We need a “safety net” treatment setting for those who cannot live in a community setting; yet, do not need a hospital (such as those with chronic mental illness, rather than a single acute episode).

LTCFs may become an option for those on Forensic Status (i.e., with criminal charges), when the individual is found Not Guilty by Reason of Insanity or Incompetent to Stand Trial. In this case, we need special highly secure forensic LTCF units, with video surveillance monitoring, security control centers, secure rooms/cells, electronically controlled doors, more security officers on staff, etc. These are mental health-equipped units, possibly funded and staffed by the local sheriff’s office, similar to the Bergen Regional Medical Center Forensic Unit in Paramus New Jersey.

They would need to reconfigure units in current facilities into specialized units (without building new buildings) in LTCFs for those with mental illness with admissions to these units stipulated by the results of an individual’s Pre Admission Screening and Resident Review (PASRR). We need to add a category to the PASRR for special services within a nursing facility, not just the option of psychiatric hospitals or community services. This should allow more robust individuals with or without medical problems and/or self-care deficits to be admitted to an LTCF when they need custodial care beyond what a group home can provide.

As suggested, some people will always require custodial care in a congregate care setting. LTCFs will help fill this gap in care for those with the most severe, disabling, and debilitating mental health conditions. Medicaid should fund LTCFs, through LTSS monies, to care for those with mental illness, so they can be discharged from hospitals to a safe setting, that has the resources to treat their mental illness, rather than homeless shelters.

Also, the State should modify its civil commitment laws to allow individuals to be committed to LTCFs, such that individuals cannot leave when they are not capable of self-preserving in the community independently without supervision.

As for me and many others, people linger in hospitals for extended periods waiting for an appropriate placement that never comes. Our system just doesn’t have the infrastructure to maintain people with mental illness in LTCFs. There needs to be an in-between step between hospitals, group homes, and supported housing. Doctors like to play it safe and avoid discharging these individuals because there is just nowhere better for them to go. An LTCF would have been an excellent alternative for people like me. Group homes and supported housing do not cut it for many people with the most severe mental illness.

We have almost 90 pages of LTCFs in New Jersey. Why can’t some of them pitch in to help those with developmental disabilities and mental illness?