Nose-down - 'it's humiliating and demeaning, but it works'

— For 15 years, when one Conway Human Development Center resident became angry, staff members ordered him to get on his knees, put his hands behind his back and place his nose on the ground.

Center administrators call the technique "nose down" and insist that it is calming.

Federal investigators call it demeaning and insist that it be stopped.

In April 2001, federal investigators from the Centers for Medicare and Medicaid Services cited the nose-down practice under its policies governing physical or psychological punishment.

The resident was a 39-year-old man admitted to the center in 1969 at age 7. He is severely mentally retarded with a psychotic disorder, obsessive-compulsive disorder and a history of seizures.

"He had a history of causing permanent, debilitating injuries to staff and other clients," according to records obtained under the state Freedom of Information Act.

"The man who has the nose-down procedure stomped a client's head in the ground about 24 years ago, put him in the hospital. He [the victim] had to have three surgeries on his brain," explained center Superintendent Bob Clark.

"We stumbled on the nose-down procedure 15 years ago, and it was a very acceptable practice," Clark said. "And frankly I would ask: Is that an acceptable practice if it works for him? If that's all that works for him?"

Clark portrayed the 5-foot-9 inch, 189-pound man as violent.

"His volatility is critical," Clark said. "The [federal] surveyors couldn't have cared less. The surveyor came in and said, 'That's wrong. It's dehumanizing. That don't look right.'"

"We may have erred in not looking at other options because that worked and he had not harmed anyone."

Clark said the man's parents gave permission for the nose-down technique, as did the Conway center's interdisciplinary team and its Human Rights Committee.

The man's May 5, 2001, assessment stated, "He can have explosive behaviors and become aggressive very quickly. He is very destructive of all clothing, bed linens, and objects in and around his bedroom area."

Staff members who worked with the man on his unit suggested, "due to the severity of aggression, enhanced supervision be continued for an indefinite time."

When the resident behaved, he earned access to reinforcing activities or privileges. These included going to the gym, outings (especially going out for breakfast), canteen, watching TV, Three Stooges movies and one-on-one attention.

Despite the characterization by Clark that the man is violent, his May 2001 files stated that "his personal income is from Social Security and off-campus employment."

For several years, the resident has been a member of a work crew that cleans parking lots at three local restaurants, files stated.

"On occasions he has been deliberately silly and attempting to entertain customers at the business," according to the files. "In some instances he has refused to get off the van and begin his work."

The man no longer works in the community but does work on campus, a Conway center spokesman said last week.

Clark compared the nose-down technique to asking a child to stand in the corner.

But records indicate it was not always as simple as that.

"When asked to go 'nose down,' if one was fortunate, he would voluntarily assume a kneeling position," records stated.

Another file states that the resident "usually complies with the nose-down procedure without need of physical intervention."

The man's file also directs "nosedown until calm for 1 minute, not to exceed 10 minutes."

The nose-down technique was used five times between December 2000 and April 2001 for between five and 10 minutes. On April 9, 2001, it was used for 25 minutes.

Federal investigators asked the Conway center's psychological examiner if the procedure would appear to be demeaning. "She believes it's humiliating and demeaning, but it works," they quoted her as replying.

When direct-care staff members were asked the same question, one person answered, "maybe it is [humiliating ], and maybe that's the point."

The nose-down practice has been discontinued, Clark said, because the federal investigators didn't like it.

Copyright © 2002, Arkansas Democrat-Gazette, Inc. All rights reserved.

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