Landmark Suit Arrives At Long-Awaited End

It took more than three decades, but the curtain has finally come down on a lawsuit filed in 1970 to guarantee that patients involuntarily committed to psychiatric hospitals have a right to adequate treatment in return for being confined against their will.

The case, Wyatt v. Sawyer, was filed as Wyatt v. Stickney 33 years ago as a class action on behalf of Ricky Wyatt, who had been civilly committed to Bryce Hospital, a state psychiatric facility in Tuscaloosa, Ala. (Stonewall B. Stickney was Alabama’s mental health commissioner at the time the suit was filed.)

Lawyers and mental health advocates were determined to improve the sorry state of what passed for treatment in the late 1960s in Alabama’s state-run psychiatric hospitals. The state had cut staffing levels and programs at Bryce and other hospitals to compensate for funds lost after the Alabama legislature slashed the state’s cigarette tax. Once the cuts were enacted, only one psychiatrist was left to treat Bryce’s 5,000 patients, and 50 cents a day was budgeted for each patient’s food. The physical plant was allowed to deteriorate severely, and advocates documented dirty and overcrowded conditions.

The advocates who initiated the lawsuit thought that a victory celebration was in order in 1972, when Federal District Court Judge Frank Johnson decided the case in favor of Wyatt and the class of plaintiffs.

Johnson ruled that involuntarily committed patients have a constitutional right to adequate treatment that might cure or improve their condition and that the judicial system has the right to intervene when a state fails to meet minimum standards for psychiatric care.

“To deprive any citizen of his or her liberty upon the altruistic theory that confinement is for humane and therapeutic reasons,” Johnson declared in his landmark ruling, “and then fail to provide adequate treatment violates the very fundamentals of due process.”

In the years following the decision, however, Alabama officials failed to improve hospital conditions in accord with the standards that Johnson had identified if the state was to meet its constitutional obligation to patients confined in its psychiatric facilities.

Johnson left very little to chance or to the mutable preferences of state health officials. He detailed standards for the psychiatric hospitals that governed such concerns as staffing ratios, development of treatment plans, nutritional requirements, and a least-restrictive-alternative standard. The judge went so far as to mandate a minimum number of toilets available to patients and the frequency with which staff had to change bed linens.

He gave the state six months to bring its psychiatric hospitals in line with the standards he laid out.

In Alabama, however, a series of governors, other state officials, and state lawmakers repeatedly failed to take the steps necessary to comply with Johnson’s requirements, including allocating sufficient funds to carry out his orders.

By 1977 the very frustrated plaintiffs went back to federal court, where they succeeded in convincing it to assign independent monitors to oversee how the state complied with Johnson’s ruling.

Nine years later, the parties entered into an agreement to fulfill Johnson’s terms, but Alabama officials continued to drag their collective feet. By January 2000 some improvements had been made, but the state hospitals were still a long way from meeting the judge’s mandate. Alabama and federal officials were able at that time to agree on a settlement in which the federal government would terminate the monitoring program, and state officials promised in return to increase funds sufficiently to complete the patient-care and facility improvements. The agreement also obligated the state “to conduct interdisciplinary team meetings and to develop individualized treatment plans” for every patient in a state psychiatric hospital.

Hospital administrators were given nine months to hire consultants who would help them establish seclusion and restraint practices and revised discharge procedures. The agreement also provided for about 600 patients to be transferred from hospitals to community care.

Finally, on December 5, 2003, U.S. District Judge Myron Thompson, who replaced the late Judge Johnson on the Wyatt case, brought the protracted legal wrangling to an end. He ruled that Alabama officials have lived up to the terms of the 2000 settlement with the federal government. Gov. Bob Riley, who was present for Thompson’s decision, stated, “We do not look at the end of the case as a diminishment of our responsibilities, but as more responsibility we have to shoulder ourselves.”

The case “had a huge impact on the care of patients in state facilities, but not for the reasons anyone would have anticipated,” explained forensic psychiatrist Paul Appelbaum, M.D. “As the odyssey of Wyatt suggests, courts had only limited success in forcing states to comply with orders to improve their facilities.”

Appelbaum, a former APA president, is chair of the psychiatry department at the University of Massachusetts and director of its Law and Psychiatry Program.

“Moreover,” he continued, “the criteria on which the courts focused tended to be those most easily measurable, as opposed to those most likely to improve the quality of treatment. But the fear of litigation after Wyatt stimulated many states to enter into consent decrees that required increased expenditures on state hospitals, or to undertake such efforts prophylactically. And Wyatt undoubtedly accelerated the closure of state facilities—clearly a mixed blessing. For better and for worse, Wyatt helped to change the face of American public-sector psychiatry.” ▪