Wyatt v. Stickney 325 F. Supp 781(M.D.
Key Issue: Patients have a "constitutional right to receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition."
In defining a right to treatment by specific staffing ratios and other objective criteria (which the state could not meet both because of expense and inability to attract sufficient professionals), the court paved the way for massive deinstitutionalization.
The precipitating factor in the Wyatt case was a cut in Alabama's cigarette tax. As a result of the budget shortfall, over a hundred employees at Bryce Hospital in Tuscaloosa, Alabama lost their jobs, twenty of them professionals (psychologists, social workers and occupational therapists). The Department of Psychology at Bryce spearheaded the suit for reinstatement brought by those laid off, and for tactical reasons added a patient, Ricky Wyatt, the nephew of one of the laid-off employees. Adding the patient enabled the suit to allege that patients' treatment suffered as a result of the layoffs. Federal District Judge Frank M. Johnson dismissed the part of the suit brought by the professionals, holding that the Alabama Department of Mental Health had the right to lay off employees, but consented to hear the part of the suit dealing with the patients' grievances.
From a broader perspective, the suit had its roots in two disparate developments. One was attorney-physician Morton Birnbaum's seminal article "The Right to Treatment" published in 1960, ten years prior to the Wyatt case. Birnbaum had advanced what was then the revolutionary thesis that each mental patient had a legal right to such treatment as would give him "a realistic opportunity to be cured or improve his mental condition." Failing that, Birnbaum argued, the patient should be able "to obtain his release at will in spite of the existence or severity of his mental illness." Birnbaum did not see the latter as a way to achieve deinstitutionalization but rather as an enforcement mechanism to impel improved hospital treatment. Alabama attorney George Dean, retained by the plaintiffs in Wyatt, decided to use Birnbaum's thesis of a "right to treatment" as the basis for his suit and Birnbaum himself became co-counsel.
The second very different development in which the Wyatt case was rooted was the rise of a mental health bar whose goal was to abolish, or if that was not possible, severely limit involuntary commitment of mental patients. Attorneys with this perspective were ambivalent about litigating a "right to treatment." Bruce Ennis, father of the mental health bar, at first refused to do so, explaining in a 1974 interview with Madness Network News, "I refused to do so because I was afraid if they [lawsuits based on the right to treatment] were successful...it would become a legitimizing stamp on involuntary confinement, another basis for depriving people of their liberty.... In other words, I don't really believe in the 'right to treatment' concept."
Despite Dean's basing Wyatt on "the right to treatment," Ennis decided to participate in the case. He explained his reason: There was "advance information" that the judge "would not only say there is something in the abstract called the 'right to treatment,' but that he would set standards so high the state would be unable to meet them and would "have to discharge many of the patients in its institutions." Winning the right to treatment, said Ennis in that same 1974 interview, would thus serve "as the best method for deinstitutionalizing thousands of persons." Along with several other attorneys opposed to involuntary commitment (they would join forces in 1972 to form the Mental Health Law Project), Ennis worked with Dean and Birnbaum on the Wyatt case.
Conditions at Alabama state hospitals were indisputably bad, making Wyatt a particularly propitious case. Physical plant, clothing, food (budgeted at 50 cents per day) were all woefully inadequate; there was a single psychiatrist for 5,000 patients; and psychologists and social workers were correspondingly scarce.
Judge Johnson ruled that patients "unquestionably have a constitutional right to receive such individual treatment as will give each of them a realistic opportunity to be cured or to improve his or her mental condition" (a direct quote from Birnbaum's formulation of the "right to treatment)," and that the programs at the hospital "failed to conform to any known minimums established for providing treatment for the mentally ill." He ruled that the due process clause of the Constitution was violated: "To deprive any citizen of his or her liberty upon the altruistic theory that the confinement is for humane therapeutic reasons and then fail to provide adequate treatment violates the very fundamentals of due process."
Judge Johnson gave the state six months to implement fully the "right to treatment" at Bryce Hospital and when, at the end of that time, it had failed to do so, he set out specific requirements the hospital would have to meet. Judge Johnson interpreted the right to treatment, as Birnbaum had argued he should, in "objective" terms -- so many professionals per so many patients, the preparation of treatment plans, a physical plant meeting certain standards. The assumption was that if these objectively measurable conditions were met, treatment would necessarily follow. Accordingly Judge Johnson not only stipulated the required proportion of psychiatrists, nurses, psychologists, and social workers to patients, but dictated the number of chaplains, messengers, dietitians, and maintenance repairmen. He stipulated how often linen had to be changed, how many showers a patient should receive, and what furniture should be in the dayroom. He even stipulated the temperature for dishwashing -- it had to be "thermostatically controlled" at 180 degrees Fahrenheit.
The state appealed and the circuit court upheld Judge Johnson's decision. In June 1977, complaining that the state was still not living up to the mandated standards, the plaintiffs succeeded in obtaining a federal court office to monitor state compliance with Wyatt standards. In 1986, although the Wyatt standards had still not been met, a settlement finally abolished that federal office in exchange for a state promise to spend more money and secure accreditation for its hospitals.
If Lessard v. Schmidt was the seminal case in drastically limiting the state's power to commit patients on parens patriae grounds, Wyatt was the seminal case in achieving drastic deinstitutionalization of previously committed patients. Following Judge Johnson's decision, there was similar litigation in a number of states, among them Louisiana, Minnesota, and Ohio. Rather than face costly court-imposed standards, some of them impossible to meet (Alabama's efforts to recruit psychiatrists were unavailing), states rapidly emptied their hospitals. In the case of Alabama, the population at its state psychiatric hospitals was reduced by almost two-thirds between 1970 and 1975 (even while expenditures were increased by 327%). The Wyatt litigation was also significant in giving birth to the Mental Health Law Project (now known as the Bazelon Center for Mental Health Law), which was created by Bruce Ennis and three other young attorneys working on Wyatt -- Charles Halpern, Paul. Friedman and Margaret Ewing. It became the ideological fulcrum of the mental health bar, further restricting involuntary treatment and creating and expanding the right to refuse treatment.
Conditions were deplorable in Alabama state hospitals and the effort to improve them commendable. However, Birnbaum -- who sought improvement -- lost out to Ennis and his Mental Health Law Project colleagues, whose goal was abolition. Birnbaum quickly fell out with the others as the prospect of victory highlighted their opposed agendas. Birnbaum, pointing out the decision raised "almost insurmountable" financial problems that could only lead to the discharge of thousands of patients, wanted to challenge the constitutionality of the 1965 Medicaid legislation that excluded state mental hospital patients under sixty-five from Medicaid benefits. Because of Medicaid's matching provisions, he calculated that if Medicaid included state mental hospital patients, Alabama would be able to quadruple its expenditures on these patients without increasing state appropriations. But the other attorneys in the case refused to participate in such a lawsuit, believing, Birnbaum says "the state mental institution system was basically bad and should be done away with..." In 1972 Birnbaum bowed out of Wyatt v. Stickney to initiate a challenge in federal court in New York to the Medicaid exclusion. It failed.
Sadly, Wyatt v. Stickney resulted in a great deal of waste of scarce Alabama mental health dollars. In an attempt to comply with Judge Johnson's ruling, the state invested an enormous sum of money on improvements to outmoded buildings which were promptly abandoned as large numbers of patients were released.
For the patients that remained, the physical plant and staffing ratios improved. But it is not clear that treatment did. Defined in "objective" terms, the right to treatment did not refer to treatment at all: purely such things as staffing ratios and physical amenities defined it. Stonewall Stickney, Alabama's mental health commissioner, would point out tellingly that some of the staffing ratios dictated by Judge Johnson (so many MSWs, so many psychologists with PhDs) catered more to the prestige needs of the professions than the needs of patients. Indeed, treatment actually suffered in important respects as a result of Judge Johnson's decision. The decision imposed severe obstacles to administering ECT, an important treatment modality. The judge also forbade "non-therapeutic labor;" the effect of this was to impose on Alabama state mental patients a regime of highly non-therapeutic idleness.
But above all, the Wyatt decision resulted in a quantum
leap for deinstitutionalization. Although in 1975, in the Donaldson case, the Supreme
Court would refuse to endorse the existence of a constitutional "right to
treatment," states were not prepared to run the risk of expensive court-ordered
overhauls of state mental hospitals. Throughout the country, patients were dumped from
hospitals, supposedly to be cared for in the community, but, as Birnbaum vainly warned,
without alternative facilities in place to care for them.
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