Right to Treatment: Wyatt v. Stickney - Case Summary - Mental Illness Policy Org
Right to Treatment: Wyatt v. Stickney – Case Summary 2017-02-01T10:51:25+00:00

Wyatt v. Stickney 325 F. Supp 781(M.D.Ala.1971),
334 F. Supp. 1341 (M.D.Ala 1971), 344 F. Supp. 373
(M.D. Ala. 1972), sub nom Wyatt v. Aderholt, 503 F.
2d 1305 (5th Cir. 1974).

Key Issue:  Patients have a”constitutional right to receive such individual treatment as will give each of thema realistic opportunity to be cured or to improve his or her mental condition.”

Summary:

In defining a right to treatment by specific staffingratios and other objective criteria (which the state could not meet both because ofexpense and inability to attract sufficient professionals), the court paved the way formassive deinstitutionalization.

Background:

The precipitating factor in the Wyatt case was a cut inAlabama’s cigarette tax. As a result of the budget shortfall, over a hundred employees atBryce Hospital in Tuscaloosa, Alabama lost their jobs, twenty of them professionals(psychologists, social workers and occupational therapists). The Department of Psychologyat Bryce spearheaded the suit for reinstatement brought by those laid off, and fortactical reasons added a patient, Ricky Wyatt, the nephew of one of the laid-offemployees. Adding the patient enabled the suit to allege that patients’ treatment sufferedas a result of the layoffs. Federal District Judge Frank M. Johnson dismissed the part ofthe suit brought by the professionals, holding that the Alabama Department of MentalHealth had the right to lay off employees, but consented to hear the part of the suitdealing with the patients’ grievances.

From a broader perspective, the suit had its roots in twodisparate 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 hada legal right to such treatment as would give him “a realistic opportunity to becured or improve his mental condition.” Failing that, Birnbaum argued, the patientshould be able “to obtain his release at will in spite of the existence or severityof his mental illness.” Birnbaum did not see the latter as a way to achievedeinstitutionalization but rather as an enforcement mechanism to impel improved hospitaltreatment. Alabama attorney George Dean, retained by the plaintiffs in Wyatt, decided touse Birnbaum’s thesis of a “right to treatment” as the basis for his suit andBirnbaum himself became co-counsel.

The second very different development in which the Wyattcase was rooted was the rise of a mental health bar whose goal was to abolish, or if thatwas not possible, severely limit involuntary commitment of mental patients. Attorneys withthis perspective were ambivalent about litigating a “right to treatment.” BruceEnnis, father of the mental health bar, at first refused to do so, explaining in a 1974interview 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 alegitimizing stamp on involuntary confinement, another basis for depriving people of theirliberty…. In other words, I don’t really believe in the ‘right to treatment’concept.”

Despite Dean’s basing Wyatt on “the right totreatment,” Ennis decided to participate in the case. He explained his reason: Therewas “advance information” that the judge “would not only say there issomething in the abstract called the ‘right to treatment,’ but that he would set standardsso high the state would be unable to meet them and would “have to discharge many ofthe patients in its institutions.” Winning the right to treatment, said Ennis in thatsame 1974 interview, would thus serve “as the best method for deinstitutionalizingthousands of persons.” Along with several other attorneys opposed to involuntarycommitment (they would join forces in 1972 to form the Mental Health Law Project), Ennisworked with Dean and Birnbaum on the Wyatt case.

Conditions at Alabama state hospitals were indisputablybad, making Wyatt a particularly propitious case. Physical plant, clothing, food (budgetedat 50 cents per day) were all woefully inadequate; there was a single psychiatrist for5,000 patients; and psychologists and social workers were correspondingly scarce.

The Decision:

Judge Johnson ruled that patients “unquestionably havea constitutional right to receive such individual treatment as will give each of them arealistic opportunity to be cured or to improve his or her mental condition” (adirect quote from Birnbaum’s formulation of the “right to treatment),” and thatthe programs at the hospital “failed to conform to any known minimums established forproviding treatment for the mentally ill.” He ruled that the due process clause ofthe Constitution was violated: “To deprive any citizen of his or her liberty upon thealtruistic theory that the confinement is for humane therapeutic reasons and then fail toprovide adequate treatment violates the very fundamentals of due process.”

Judge Johnson gave the state six months to implement fullythe “right to treatment” at Bryce Hospital and when, at the end of that time, ithad 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 preparationof treatment plans, a physical plant meeting certain standards. The assumption was that ifthese 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 ofchaplains, messengers, dietitians, and maintenance repairmen. He stipulated how oftenlinen had to be changed, how many showers a patient should receive, and what furnitureshould be in the dayroom. He even stipulated the temperature for dishwashing — it had tobe “thermostatically controlled” at 180 degrees Fahrenheit.

The state appealed and the circuit court upheld JudgeJohnson’s decision. In June 1977, complaining that the state was still not living up tothe mandated standards, the plaintiffs succeeded in obtaining a federal court office tomonitor state compliance with Wyatt standards. In 1986, although the Wyatt standards hadstill not been met, a settlement finally abolished that federal office in exchange for astate promise to spend more money and secure accreditation for its hospitals.

Significance:

If Lessard v. Schmidt was the seminal case in drasticallylimiting the state’s power to commit patients on parens patriae grounds, Wyatt was theseminal 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-imposedstandards, some of them impossible to meet (Alabama’s efforts to recruit psychiatristswere unavailing), states rapidly emptied their hospitals. In the case of Alabama, thepopulation at its state psychiatric hospitals was reduced by almost two-thirds between1970 and 1975 (even while expenditures were increased by 327%). The Wyatt litigation wasalso significant in giving birth to the Mental Health Law Project (now known as theBazelon Center for Mental Health Law), which was created by Bruce Ennis and three otheryoung attorneys working on Wyatt — Charles Halpern, Paul. Friedman and Margaret Ewing. Itbecame the ideological fulcrum of the mental health bar, further restricting involuntarytreatment and creating and expanding the right to refuse treatment.

Comment:

Conditions were deplorable in Alabama state hospitals andthe 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 theiropposed agendas. Birnbaum, pointing out the decision raised “almostinsurmountable” financial problems that could only lead to the discharge of thousandsof patients, wanted to challenge the constitutionality of the 1965 Medicaid legislationthat excluded state mental hospital patients under sixty-five from Medicaid benefits.Because of Medicaid’s matching provisions, he calculated that if Medicaid included statemental hospital patients, Alabama would be able to quadruple its expenditures on thesepatients without increasing state appropriations. But the other attorneys in the caserefused to participate in such a lawsuit, believing, Birnbaum says “the state mentalinstitution system was basically bad and should be done away with…” In 1972Birnbaum bowed out of Wyatt v. Stickney to initiate a challenge in federal court in NewYork to the Medicaid exclusion. It failed.

Sadly, Wyatt v. Stickney resulted in a great deal of wasteof scarce Alabama mental health dollars. In an attempt to comply with Judge Johnson’sruling, the state invested an enormous sum of money on improvements to outmoded buildingswhich were promptly abandoned as large numbers of patients were released.

For the patients that remained, the physical plant andstaffing 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. StonewallStickney, Alabama’s mental health commissioner, would point out tellingly that some of thestaffing 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 treatmentmodality. The judge also forbade “non-therapeutic labor;” the effect of this wasto impose on Alabama state mental patients a regime of highly non-therapeutic idleness.

But above all, the Wyatt decision resulted in a quantumleap for deinstitutionalization. Although in 1975, in the Donaldson case, the SupremeCourt would refuse to endorse the existence of a constitutional “right totreatment,” states were not prepared to run the risk of expensive court-orderedoverhauls of state mental hospitals. Throughout the country, patients were dumped fromhospitals, supposedly to be cared for in the community, but, as Birnbaum vainly warned,without alternative facilities in place to care for them.