The annual gathering of the American Psychiatric Association is a dignified and collegial affair, full of scholarly exchanges, polite laughter and polite applause.
So it was a shock, for those who took their seats in Room 1E08 of the Jacob K. Javits Convention Center in Manhattan, to watch a powerfully built 32-year-old man choke back tears as he described being slammed to the floor and cuffed to a stretcher in a psychiatric unit.
Because the man, Matthew Tuleja, had been a Division I football player, he had a certain way of describing the circle of bodies that closed around him, the grabbing and grappling and the sensation of being dominated, pinned and helpless.
He was on the ground in a small room filled with pepper spray. Then his wrists and ankles were cuffed to the sides of a stretcher, and his pants were yanked down. They gave him injections of Haldol, an antipsychotic medication he had repeatedly tried to refuse, as he howled in protest.
Forcible restraints are routine events in American hospitals. One recent study, using 2017 data from the Centers for Medicare and Medicaid Services, estimated the number of restraints per year at more than 44,000.
But it is rare to hear a first-person account of the experience, because it tends to happen to people who do not have a platform. Researchers who surveyed patients about restraint and seclusion have found that a large portion, 25 to 47 percent , met criteria for post-traumatic stress disorder.
Listening, rapt, to Mr. Tuleja was a roomful of psychiatrists. It was a younger crowd — people who had entered the field at the time of the Black Lives Matter protests. Many of them lined up to speak to him afterward. “I still can’t forget the first time I saw someone restrained,” one doctor told him. “You don’t forget that.”
In study after study, hospitals have proved that it is possible to reduce the use of coercive force in psychiatry. But it requires sustained effort. It also means balancing patient welfare against the safety concerns of nurses, who are frequently injured in psychiatric settings. De-escalation takes time, and when systems are understaffed, they may default to force as a matter of efficiency.
Dr. Samuel W. Jackson, one of the panel’s hosts, said he hoped that his generation of psychiatrists would usher in change around the practice.
“I believe that Matt, in telling his story, puts a mirror in front of all of us, allowing us to focus on some of the ugliest aspects of our work,” said Dr. Jackson, the co-director of Public Psychiatry Education at SUNY Downstate Health Sciences University.
“Hearing this story, I was initially disturbed, and then at one point, if I’m being honest, a bit defensive,” he said. “However, eventually — and I think that’s where I am now, thinking about this story — I started questioning this idea that putting people in restraint and seclusion is just part of the job.”
A career derailed
“It was all sunshine and rainbows until I was 15,” Mr. Tuleja told the crowd at the Javits Convention Center. There were obsessive rituals, for sure: He adjusted his pads again and again, convinced that otherwise he wouldn’t perform well. But plenty of superstar athletes have rituals, the toe taps and helmet touches.
Then, when Matthew was a freshman in high school, “he just fell off the turnip truck,” said his father, Stephen, an electrical engineer. His grades dropped. He began exploding in anger at home. His first inpatient stay was at a hospital that was eventually shuttered over its squalid conditions. “I just remember thinking, like, what the heck happened to my life?” Mr. Tuleja told the audience.
Two years passed before he received a diagnosis that made sense to him: obsessive-compulsive disorder. Under the care of a specialist, he practiced reining in his rituals and was able to return to football. In his first year playing for the University of Massachusetts, N.F.L. scouts began calling. For a while, it seemed that the hardest time was behind him.
Then the anxiety returned. In 2015, he took a leave of absence and enrolled in an inpatient program. His treatment was structured around exposure and response prevention therapy, which requires patients to expose themselves to what they fear. For him, that meant repeating a script of foul insults directed at himself, a process so distressing that he sometimes threw up.
This time, the treatment seemed to only make things worse.
Frustrated, anxious and depressed, he moved back home with his parents. It was a miserable time; he recalled watching his team play Notre Dame while he was “in the fetal position in my parents’ basement, sweating off benzos,” drugs sometimes prescribed for anxiety. He blamed his former therapist for setting him on such a punishing course of therapy. After requesting a formal review of his treatment with no result, he talked about confronting the man in person.
Medical records from Massachusetts General Hospital that Mr. Tuleja shared with The New York Times help explain how a violent restraint was set in motion.
“Matt is obsessed with holding this doctor accountable and needs help,” Stephen Tuleja had written to his son’s psychiatrist. “Patient has said over the past couple of weeks that he was going to go yell at” the former therapist “or punch him in the face,” noted an emergency room psychiatrist.
Further back in the records, there was another alarm bell. During a therapy session the previous August, Mr. Tuleja expressed such frustration toward his former therapist that his current therapist passed on a Tarasoff warning, a breach of confidentiality that is required when patients make credible threats against a third party.
Jessica A. Pastore, a spokeswoman for Massachusetts General Hospital, said patient privacy laws prevented the hospital from commenting on Mr. Tuleja’s account. But she said that restraints “are not used unless it is determined by hospital staff that an individual is an immediate threat to themselves, staff or others.”
The use of pepper spray is exceedingly rare, she said, occurring once or twice a year, “when people are afraid for their lives and for others.” The decision is made by security staff rather than clinicians. “We have health care providers who are assaulted every day by patients,” she said. “It is imperative that we are able to protect our employees.”
Dec. 8, 5:26 p.m.
On the morning of Dec. 8, 2015, Mr. Tuleja set off alone to find his former therapist. He denies any intention to hurt the man; his medical records reflect no history of assaulting anyone. “I wanted to have a closure conversation, and treat the gripe I had with my psychologist the way I would a player or coach who I had an issue with,” he said.
His father, who had tracked his phone, realized he was headed for the hospital where the therapist worked. “We advise him not to,” he said. “He goes anyway. I call the psychiatrist. I call the psychologist. I call the manager. I say, look, he’s coming. You probably shouldn’t talk to him. They all agree.”
He persuaded Mr. Tuleja to pull into a Dunkin’ Donuts parking lot. Then, in a series of phone calls with doctors, he agreed to bring his son into the emergency room. The hospital had set two options before him, he said: Bring Matt in, or the police would put him under an emergency mental health commitment.
These were the circumstances when they entered the hospital together that afternoon. Drained from the events of the day, Mr. Tuleja thought he was going to the hospital for a medication check.
But staff there were on high alert, medical records show. “Sent in by outpatient psychiatrist after patient confessed plan and intent to physically threaten” his therapist, the notes say. Beside “diagnosis,” the E.R. psychiatrist wrote “acute homicidal ideation in patient with history of O.C.D., depression, borderline personality.”
A process had been set in motion. At 4:03 p.m., a half-hour after he arrived at the emergency room, Mr. Tuleja was “sectioned,” or put under an emergency mental health commitment, the notes say. That meant that he no longer had the right to refuse medication. But Mr. Tuleja said he didn’t know that.
He found himself in a small room with a psychiatrist; she wanted him to take Haldol, an antipsychotic medication, which he refused. The doctor asked again; he refused again. A third time she asked. He refused.
The tension in the small room was rising, according to his father, who was present. “I thought he was relatively calm,” he recalled. “But the minute they said Haldol,” he added, “he went on high alert.”
One of the staff asked Mr. Tuleja’s father to step out of the room into the main corridor. The door latched behind him. Then the doctor returned to the locked room with more staff — Mr. Tuleja counted nine. Inside psychiatric units, this is sometimes called a show of force, a signal to the patient to stop resisting.
It didn’t work that way with Mr. Tuleja. He described backing up in the small exam room until his back was against the wall. He crossed himself and said the “Our Father” prayer, an old football habit.
Opposite him, by the door, were the burly guards. But he was a fullback, a specialist in finding a hole. He described a split-second decision, born of thousands of hours of training.
“I attempted to run out of there like an N.F.L. running back,” he said.
But there wasn’t a hole. The last thing he heard was a warning from one of the guards, who said he would be legally accountable if he hit them. The room filled with pepper spray, and the men were on top of him. He remembers being face down, under bodies, and hearing someone ask, “Are you going to be a good boy?” They cuffed him to the bed and gave him the shots. He remembers being alone in the dark, the pepper spray stinging his eyes, his genitals.
At this point in his presentation, Mr. Tuleja began to cry.
Records from Massachusetts General Hospital tell the same story, but differently. “Security officers tried to guide the patient to the stretcher, whereupon he became combative,” a nurse noted at 5:26 p.m. “Security then had to resort to pepper-spraying the patient.” He was placed on the stretcher in four-point restraints.
Eighteen minutes later, a nurse noted: “Patient crying, yelling that ‘I told you I can’t take those medications.’” Thirty-four minutes later: “Patient yelling, ‘I just want these taken off.’” Twenty minutes after that: “He remains nonsedated, restless on stretcher.” One hour and 16 minutes after the initial restraint, a nurse gave him another injection, this time of Thorazine. At 8:50 p.m., the four-point restraints were removed.
Mr. Tuleja was transferred to another hospital and sent home a few days later. But the memory of the restraint would not leave him alone.
When he returned to the University of Massachusetts for his senior year, he told the audience, he found it difficult to focus, and his grade-point average slid to 1.0, from 3.5, he said. Never mind football. When he was playing, he said, “I was having thoughts about the defense pulling my pants down and shoving a needle in me.”
‘You don’t forget’
In the audience, Dr. Kate Boudreau was weeping. As a first-year psychiatry resident at a clinic in Brooklyn, N.Y., she had seen people restrained — in the name of safety — in ways that she described as “really forceful.” She had never heard an account like Mr. Tuleja’s, and it gave her chills.
“No human being should have an experience like this within the mental health system,” she said. She hoped that her cohort of psychiatrists, powerfully shaped by the Black Lives Matter movement and the coronavirus pandemic, would be able to change practices.
“We don’t have to do things the way they have always been done,” she said.
Quentin C. Shambley, a psychiatric nurse practitioner from Phoenix who was also in the audience, was thinking about a restraint from 2016 that still bothered him. The patient was a skinny, disheveled man, psychotic or maybe on drugs, and he had hurt a staff member. The restraint that followed felt uncomfortably like retribution, he said.
“What I saw was an elbow, an elbow with weight on it, on the back of this patient’s neck, and he appeared to be yelling out or crying out for help,” he said. When he got home, he told his wife about it. He tried to bring it up with his co-worker, but the criticism wasn’t welcome, and he backed off.
“I feel like I could have been more direct,” Mr. Shambley said. “I could have said more after the fact. I could have done more in the moment.”
Though Massachusetts General Hospital would not comment on Mr. Tuleja’s experience, its spokeswoman recommended a conversation with Dr. Dana D. Im, director of quality and safety for the system’s emergency medical services.
Dr. Im said hospital leadership had been jolted by data gathered in 2018 and 2019 that showed Black patients were significantly more likely to be restrained than their white or Asian counterparts.
“We struggled with this data when we first analyzed it, and we decided against brushing it under the rug,” she said.
In 2022, the hospital system introduced a standardized protocol intended to correct for bias in staff assessments of dangerousness. The use of restraints on patients in a psychiatric hold dropped significantly — to 3.7 percent, from 7.4 percent, in one of the system’s hospitals.
After the A.P.A. meeting concluded, Mr. Tuleja returned home to Massachusetts. He is studying for the LSAT, and this week launched a website for Matt’s Mission, a patient advocacy organization he founded that aims to reduce patient maltreatment in psychiatry.
Dr. Jackson, who had appeared alongside him on the panel, returned to his duties at Kings County Hospital Center, in Brooklyn. He had pored over Mr. Tuleja’s medical records, in search of “almost like an explanation,” he said. “Like, why did this happen? Can you see a reason?”
But he found nothing that struck him as out of the ordinary for emergency psychiatry. The hospital’s decisions appeared to be driven by Mr. Tuleja’s history of threats about his therapist rather than his behavior in the emergency ward, Dr. Jackson said. He found little information about how staff tried to de-escalate. The use of pepper spray continues to trouble him.
It was still on his mind on Saturday night, when he worked his regular shift in a psychiatric emergency room. A large, strong boy of 11 was threatening to hurt the nurses, and he flung his plate of food, sending green peas in all directions. A nurse asked Dr. Jackson to order medications, and he found himself hesitating, and then stepping into the boy’s room and sitting down next to him.
The night passed without a single restraint, and that was something.
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