APPROPRIATE CARE IN THE APPROPRIATE SETTING:
REFORMING BRIDGEWATER STATE HOSPITAL & STRENGTHENING
THE COMMONWEALTH’S MENTAL HEALTH SYSTEM
The Departments of Correction and Mental Health share the
overarching goal that individuals in Massachusetts who suffer from mental
illness should receive the appropriate care in the appropriate setting, even
where those individuals have come into the custody of the Commonwealth
through the criminal justice system. On May 8, 2014, both Departments
conveyed that foundational principle at a meeting convened by Governor
Deval Patrick at Bridgewater State Hospital, which included numerous
stakeholders from the state’s mental health and criminal justice systems.
The policy recommendations set forth in this document were
discussed in very broad strokes at that meeting and have been developed
further over the past month, through (i) extensive discussions and
exchanges of ideas with stakeholders; and (ii) extensive internal work at
the Departments of Correction and Mental Health and the Executive Offices
of Public Safety and Security and Health and Human Services.
Bridgewater State Hospital (BSH) exists by statute, which provides
that it shall be operated by the Department of Correction and that patients
shall not be admitted to it without a court order committing them, after a
finding that, among other things, the patient requires a strict security setting
for the safety of that individual and others. For certain patients, particularly
those who have been convicted of serious criminal behavior and sentenced
to a correctional institution, BSH may — with the appropriate
improvements, described below — be the appropriate setting. For others,
particularly those who, although charged with a crime, have not been
convicted of any criminal wrongdoing, a secure hospital outside of a
correctional setting might provide a more therapeutically appropriate
environment. No such institution currently exists. As we propose below,
the Administration, working with the Legislature, will address that need.
In the more immediate term, the court system, the Department of
Mental Health, and the Department of Correction need more options and
more resources to address the needs of the mentally ill whose paths have
intersected with the criminal justice system. If the appropriate setting for
the treatment and assessment of an individual is in the custody of the
Department of Mental Health, we need the open beds and funding to
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provide that treatment and those assessments. If the appropriate setting is
in the community, our court clinics require the resources to allow them to
conduct the required assessments outside of hospital or correctional
settings. If the appropriate setting is correctional, improved treatment will
require additional clinical staffing and more extensive training at BSH. The
work has been done to identify and crystalize these needs. Below, we
describe the overarching goals of our work and a proposal to seek the
resources needed to achieve them.
The issue of how best to treat mentally ill individuals who have come
into contact with the criminal justice system is complex and cannot be
solved with a “magic bullet.” The experience not only of this
Commonwealth, but of every state in the country has taught us as much.
Nonetheless, we can and must do better.
To that end, DOC and DMH have identified the number of achievable,
short-term (60 days or less), intermediate-term (6 months or less), and
long-term (more than 6 months) goals for improvements to the continuum
of care for mentally ill persons who require assessment and treatment in
the context of their involvement in the criminal justice system. Work has
already begun, and to extent of available resources, progress has already
been made to achieve these goals.
GOAL: To prevent the use of seclusion and restraint at BSH, using a
treatment model that is trauma-informed. (Short-term; ongoing)
Steps already completed:
 Substantial Prevention. BSH has significantly reduced the use of
seclusion and restraint by implementing a variety of individualized
clinical management strategies. Since January 2014, the total
number of restraint hours at BSH is down by over 90%. The total
number of seclusion hours is down by more than 50%.
 Consultation and Training. BSH leadership and staff have
completed a four-day consultation session with nationallyrenowned expert Dr. Joan Gillece. Among other prominent roles,
Dr. Gillece is the Project Director for the National Center for
Trauma Informed Care, which is operated by the federal
Substance Abuse and Mental Health Services Administration. The
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consultation addressed evidenced-based strategies for trauma
informed care and the prevention of restraint and seclusion. The
consultation will be ongoing, as Dr. Gillece will assist DOC and
DMH as they establish a comprehensive and effective training
program for BSH staff designed to prevent the need for seclusion
and restraint.
 Expansion of Treatment Options. A key step in the reduction of
seclusion and restraint is the introduction of other treatment and
de-escalation options for clinicians at BSH. As described below,
DMH continues to work with DOC to develop these options, but
several already have been implemented at BSH, including, for
example, sensory integration and the use of weighted vests.
These interventions are among those that have been shown to be
effective in providing patients with methods to de-escalate and
calm themselves in ways that avoid confrontations that often lead
to restraint and seclusion.
Next steps:
 Environmental Improvements to BSH. Two senior DMH officials
— Assistant Commissioner Debra Pinals, MD and Director of
Systems Transformation Janice LeBel, Ph.D. — have conducted
an environmental scan of BSH to determine where and how the
environment of care (including alternatives to seclusion and
restraint) can be improved. Improvement to the environment of
care will include increased clinical staffing (addressed further
below).
 Infrastructural Assessment of and Improvements to BSH. In the
Capital Investment Plan, the Administration will include $500,000
for an infrastructural assessment of and improvements to BSH.
The goal of the assessment and resulting renovation is to develop
appropriate spaces for patient de-escalation and rehabilitation,
which will afford BSH staff additional tools to manage challenging
patients and to deescalate episodes that otherwise might require
the use of seclusion or restraint.
 Increased Collaboration Between DOC and DMH. DOC will work
with DMH to implement, on a day-to-day basis, the approaches
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introduced by Dr. Gillece. Dr. LeBel, herself a nationally renowned
expert in this field, will be the in-state resource to provide ongoing
consultation and technical assistance to staff at BSH regarding
restraint and seclusion prevention and the use of trauma-informed
care. In addition, and subject to the appropriation of $325,000,
DOC and DMH will work together on ongoing, in-depth training for
BSH staff.
 More Detailed Data Collection. Within the next month, DMH
Assistant Commissioner of Quality Utilization and Analysis Terri
Anderson will review the existing seclusion and restraint data
collection program at BSH and will make recommendations for an
updated and more comprehensive system for recording, tracking
and monitoring seclusion and restraint data, including efforts at
prevention. This enhanced data will inform the collaborative effort
between DOC and DMH to reduce the triggers for episodes giving
rise to seclusion and restraint, and to develop effective alternatives
to seclusion and restraint.
GOAL: Recognizing that the decision to commit a patient to BSH is a
judicial determination that often involves the various District
Attorneys, DOC and DMH will work together to ensure that patients at
BSH receive the appropriate care, including a treatment plan that,
where appropriate, is tailored to achieve a transition to a less
restrictive setting. (Short- and mid-term)
Steps already completed:
 DOC and DMH Collaboration. DOC and DMH have had a longstanding working relationship aimed at stepping patients
committed to BSH down to a DMH facility, where appropriate.
This working relationship has been strengthened and reinforced,
to the extent that DOC and DMH are in daily contact to identify
individuals who may be appropriately transitioned to DMH care —
and to discuss the treatment plan for those who may be stepped
down in the near future.
 BSH Review of Patient Population and Resulting Step Downs. In
May 2014, DOC, with DMH consultation, has reviewed the cases
of each individual committed to BSH pursuant to G.L. c. 123, §§ 7,
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8, to determine whether a transition to DMH care might be
appropriate. These are individuals whose criminal cases have
been resolved, but who were determined by a court to require
continued care and treatment in a strict security environment.
Within the past month, at least 16 patients have already been
stepped down to DMH, and DOC has initiated the process for
obtaining judicial approval for transfer to DMH for others.
Next steps:
 Increase in DOC Staffing. Increased clinical staffing at BSH is
critical to the success of this initiative in nearly every respect —
increased staff yields more effective individualized treatment plans
and a greater capacity to deescalate acute events. Working with
DMH, DOC and its health care vendor have identified a present
need for 130 additional full time clinical employees, at a cost of up
to $10 million. These employees will augment the current staff of
psychiatrists, psychologists, nurses and mental health workers. If
this funding is appropriated promptly, DOC and its vendor believe
that these clinical resources may be added by September 1, 2014.
 Enhanced Clinical Care Coordination. DOC and DMH will
enhance existing clinical care coordination between BSH and
DMH when patients are “stepping down” to a DMH facility, and
when patients who have received treatment at DMH are committed
by a court to BSH. DOC and DMH will increase collaboration
regarding alternative interventions utilized to decrease the use of
seclusion/restraint and determine how to incorporate these
strategies into the BSH repertoire of alternative interventions to
prevent the use of seclusion/restraint.
 Department of Developmental Services (DDS) Assessments.
DOC will work with DDS to facilitate on-site reviews for DDS
eligibility and, if deemed eligible, explore possible discharge
planning to the community.


Collaborative Review of Practices and Policies at BSH. With
DMH, DOC has undertaken a review of existing facility safety
programs with a focus on potential enhancements in the areas of
rights, responsibilities, and respect across all members of the
hospital community, including staff, patients and administration, to
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carry consistent messaging about the goal of non-violence in the
correctional environment. DMH will also share its current policies
in this area so that a greater emphasis on clinical goals can be
studied and potentially adopted (e.g., institution of more clinically
focused BSH stand-alone procedures). DOC will also review and
revise DOC/BSH policies and procedures to reflect the
implementation of training initiatives. Policy revisions stemming
from this review will be completed on or before September 1,
2014.
GOAL: To enhance the range of options available to the courts when
a defendant presents with symptoms of acute mental illness. (Shortand mid-term)
Next Steps:
 Increase Number of Court Clinicians & Decrease Need for
Forensic Evaluations at BSH. Throughout the Commonwealth,
court clinicians are DMH employees (or employees of a DMH
vendor). The court clinics do not presently have the capacity to
expand their services to encompass increased numbers of
evaluations in community or jail settings. With a $1 million
investment in this workforce, court clinicians would be better
equipped to conduct forensic evaluations for individuals in the
community or, alternatively, individuals held in a correctional
setting on bail/dangerousness grounds. We expect this increased
capacity will reduce the number of non-sentenced patients
committed to BSH.


Increase DMH Capacity. If DMH and DOC are to work together to
step down BSH patients to a DMH setting (where appropriate and
with court approval), a DMH placement must be available for that
patient. Moreover, if a court determines that a defendant requires
an inpatient clinical evaluation, DMH is an option only to the extent
that it has a bed available. While DMH has been able to
accommodate the need for forensic evaluations under current
conditions, any significant increase in admissions from the criminal
courts or in step-downs from BSH will exceed its capacity to
accept those admissions as well as transfers of patients from
private psychiatric hospitals who also require DMH inpatient
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continuing care. Meaningfully addressing DMH's inpatient
capacity will affect the range of options available to the courts (in
making placement determinations) and DOC and DMH (in making
placement recommendations). Two steps will address that
capacity. First, DMH has identified 100 patients in its continuing
care inpatient system who are discharge ready, but for whom there
are insufficient community placements. The funding of 100
community supported placements for these discharge-ready
patients will free up 100 DMH inpatient beds. Second, funding 52
available (but currently unfunded) beds at the Worcester Recovery
Center and Hospital (WRCH), would add an additional 52 beds.
We will work with our partners in the Legislature to fund each of
these 152 placements.
 Judicial Cooperation. If the range of options available to the court
system is enhanced, DOC and DMH will work together with the
courts to develop extensive guidance concerning an appropriate
placement for individuals in the criminal justice system who
present with acute mental health needs. In the longer term, this
cooperation may require legislative change, as described below.
GOAL: To develop an inpatient forensic mental health hospital to be
operated by the Department of Mental Health, that can provide the
range of security necessary for the treatment and forensic
assessment of non-sentenced individuals outside of a correctional
environment. (Long-term)
Next Steps:
 Capital Expenditure on Feasibility Assessment. At present, the
Commonwealth does not have a facility capable of treating
individuals who require mental health treatment and clinical
assessment in a medium-security setting. Because of the safety
needs of the community, other DMH patients, and DMH clinicians
and staff, no current DMH facility is equipped to handle this
population. Accordingly, with enactment of the General
Government Bond Bill (S 2187) which recently passed the Senate,
the Administration will commit $500,000 in the FY15 Capital
Investment Plan to assess the feasibility of retrofitting an existing
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state facility to accommodate this population or, alternatively, to
designing a new facility.
 Legislation. Statutory revision will be required to establish such a
facility under DMH jurisdiction, to delineate necessary distinctions
between that facility and DMH's civil continuing care inpatient
facilities and to outline the criteria by which an individual may be
committed to its care. We will introduce legislation on or before
July 1, 2014 that will set forth the Administration’s position on the
required revision and we welcome the constructive input of the
mental health and criminal justice stakeholders on that important
task.

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