The late Dr. Stonewall B. Stickney was a writer for The Harbinger between the years 1986 and 1996. It is while at this job that he penned a column titled “Ask Dr. Salvo.” Dr. Stickney, or Stone, as he was known by his friends, was a crucial figure in the field of public health psychiatry (Yarbruogh, 2001). He played a critical role in public health in his capacity as the Alabama State Commissioner of Mental Health (Raskin, 2004). It was at this time that the Supreme Court ruling of 1971 found it unconstitutional the way mental health patients were housed in state institutions for long periods without any treatment being administered to them.
Consequently Dr. Stonewall initiated the famous Wyatt vs. Stickney lawsuit. This suit did not start out with that name initially, but was filed by a group of psychologists from the University of Alabama (Minis & Freyer, 2001). Stone and the Alabama Board of Mental Health wanted to make some big changes. There was a shortfall in funding due to cigarette taxes. Their rationale was to lay off some members of staff, starting with some of the executives at the top. They wanted to keep most caregivers there that were with the patients most of the time. At that time, the two sources of employers in Tuscaloosa were the University of Alabama and Bryce and Partlow Hospitals.
In October 1970, Ricky Wyatt, a fifteen-year-old boy who had always been labeled a “juvenile delinquent” and who stayed at Bryce despite not being diagnosed with a mental illness, became the named plaintiff in the Wyatt vs. Stickney lawsuit (Yarbruogh, 2001). His aunt, W. C. Rawlins, was one of the employees at the Bryce hospital who had been sent off.
Together, the two testified about intolerable conditions and improper treatments and care designed only to make the patients more manageable. In 1971, the plaintiff class was expanded to accommodate patients at Alabama’s two other mental health facilities. These were Searcy Hospital and Camp Partlow (Raskin, 2004). The resultant court ordered agreements formed the basis for federal minimum standards for the care of patients with mental illness or mental retardations who resided in institutional settings.
Wyatt vs. Stickney
In 1999, a new settlement agreement was enacted leading to a great and substantial level of progress. The case was finally dismissed on December 5, 2003, with the finding by Judge that Alabama was in compliant with the agreement (Minis & Freyer, 2001).
The standards elaborated in that agreement have over the years served as a masterpiece nationwide. Referred to as the “Wyatt Standards,” they are founded on four pre-requisites of care:
l Humanely Psychological and Physical Surrounding
The environment and surroundings within which the mental patients were to be held, according to this agreement, had to cater for their physical and psychological wellbeing (Raskin, 2004). This included the treatment from the members of staff.
l Qualified , Competent and Sufficient Staff for Administration of Treatment
The members of staff for the institutions had to meet three criteria. They must be qualified to handle the duties that they are entrusted with. The members of staff also have to be competent, meaning that they can effectively perform their duties. The members of staff also have to be adequate to handle the number of patients that they are entrusted with. This will greatly reduce the health care giver to patient ratio.
l Individualized Treatment Plans and Programs
According to this settlement, the one size fits all programs will no longer apply. Every patient has to be treated individually, given that each and every patient has unique needs and requirements.
l Minimal Restriction of Patient’s Freedom
This standard recognizes that despite their status as patients, the latter do not cease to be human beings (Yackle, 2004). As such, the restrictions imposed on their freedom by the care givers have to be minimal.
The case of Wyatt vs. Stickney came to a conclusion after 33 years (Yackle, 2004). It spanned through nine Alabama governors and fourteen state mental health commissioners. As a result of this, it is regarded as the longest running mental health case in national history (La Fond & Dulham, 2002).
Relationship between Past Events and the Current Policy
In 1970, Alabama was ranked last among American states in funding for mental health. Bryce Hospital at that time had 5,200 mental patients living in conditions that were akin to those of a concentration camp (Springer, 2005). The same year, a tax on cigarette aimed at mental health treatment was slashed. One hundred Bryce employees were sent off, including twenty members of professional staff (Yackle, 2004). Members belonging to the Department of Psychology at the Alabama University attempted to file a lawsuit on behalf of the laid down workers, but Johnson Federal Judge ruled that the courts had no powers to intervene on behalf of fired employees (Weiner & Wettstein, 2002). The judge however pointed out the possibility of a suit being filed on behalf of patients, whose quality of care was badly affected (Weiner& Wettstein, 2002).
The historic 1970 Alabama case recognized for the first time that the constitutional rights of mentally disabled patients living in state ran psychiatric hospitals had been violated and undermined under the 14th Amendment (La Fond & Dulham, 2002). This case had far reaching consequences and interest beyond the state of Alabama. As a matter of fact, Judge Johnson’s ruling forever changed the way mental health services would be delivered in the United States of America and beyond (Raskin, 2005).
The Wyatt vs. Stickney lawsuit resulted in minimum standards for the care and rehabilitation of people with mental ailments and mental retardation throughout the nation. This lawsuit, filed on October 23, 1970, was finally dismissed on December 5, 2003 (Springer, 2005).
In 1970, Bryce State Hospital in Tuscaloosa, Alabama, had 5,200 patient living in inhuman conditions and receiving substandard medical treatment (Johnson & Freyer, 2001).
Remembering what he had seen in his coverage of the Nazi war trials, Hal Martin- the editor and publisher of The Montgomery Advertiser, went so far as to point out the conditions at Bryce and the state’s other mental health institutions to be similar to those at concentration camps (Yackle, 2004). Few members of the public were conversant with the horrible and deplorable living conditions and treatment of patients in these hospitals.
In that year, as earlier indicated, a cigarette tax whose income was aimed at funding mental health services was slashed (Raskin, 2004). As a result, Bryce was forced to fire almost one hundred of its employees. Of the employees fired, 20 were professionals such as psychologists, social workers and occupational therapists. As a result of the layoffs, only one physician catered for about 350 patients, while one nurse catered for 250 patients (Yarbruogh, 2001). The same applied to psychiatrists, whereby one psychiatrist catered for about 1,700 patients (La Fond & Dulham, 2002).
The staffing ratios and conditions at the Partlow State School and Hospital in Tuscaloosa and the Searcy Hospital in Mount Vernon were worse. At Searcy, only one registered nurse attended to all the 2,500 patients and she was not permitted to access the male wards (Springer, 2005). This particular lawsuit was filed on October 23, 1970, on behalf of Ricky when the Bryce send offs were carried out (Raskin, 2004).
Additionally, the lawsuit emanated from two occurrences in the care and interventions of people with mental illness. The first occurrence involved the research and writing of attorney cum physician Morton Birnbaum who published an article in 1960 entitled The right to treatment (Yarbruogh, 2001). In this article, Birnbaum pointed out that each person in a mental institution had a fundamental right to treatment that would ultimately give the person a chance to be cured or improve his mental condition (Springer, 2005). Birnbaum held the opinion that if the person did not receive appropriate treatment, they were to be released at will despite severe condition of his mental illness.
This theory was not used as an enforcement mechanism, or rather, a tool to force adjustments in the treatment and attention given to people with mental illness residing in hospitals and other institutions (Minis & Freyer, 2001).
The second occurrence that prompted the lawsuit was the rise of a mental health bar, whose goal was to abolish or impose a limited involuntary commitment of people with mental illness to institutions (Minis & Freyer, 2001).
Fulfillment of Policy Makers’ Intention
The plans and programs for a state hospital for the mentally ill in the state of Alabama began in 1852 (Raskin, 2004). The new facility was planned from the start to utilize the “moral architecture” concepts of 1830s activist Dorothea Dix. Dix’s reformist ideas, in particular, are credited as the ones that played a pivotal role in the construction of the hospital (Weiner & Wettstein, 2002). Construction of the building began in 1853 and completed in 1859. The hospital was the first building in Tuscaloosa state with gas lighting and central heating (Yackle, 2004).
The Alabama Insane Hospital was opened in 1861. It was later renamed after its first psychiatrist superintendent, Peter Bryce, who was 27 years old (Yarbruogh, 2001). Bryce had been conversant with the hospital through his colleague Dix. His tenure was marked by absolute and diligent discipline among the staff of the hospital (La Fond & Dulham, 2002).
He demanded and pushed for patients to be treated with courtesy, kindness and respect at all times. The use of shackles and other restraints was effectively discouraged and condemned, and finally abolished altogether in 1882 (Raskin, 2004). Various programs and other activities were in effect encouraged, such as farming, sewing, maintenance and crafts. Between the period 1872 and the early 1880s, some of the patients wrote their own newspaper, The Meteor (Raskin, 2004). These contributions provided a rare and informative look at life in a mental institution in the late 19th century (Springer, 2005).
Moving Closer to or Away from Social Welfare Goals?
Governor Riley had announced on December 30, 2009, that Bryce Hospital was to relocate to a new facility across McFarland Boulevard in Tuscaloosa, and that the Alabama University was to take over the current Bryce campus. For several years, the university had a parcel of land, which was adjacent to its campus (Minis & Freyer, 2001).
Riley pointed out that a hospital of about 268 patients had been envisioned but the final size had yet to be arrived at. The deal, approved by Governor Bob Riley and Alabama Department of Mental Health on December 30 thee same year, was worth $72 million for Mental Health to build another hospital. The university was to pay $50 million and Mental Health was to get another $22 million in state bond money (Yackle, 2004). The Alabama university had pledged another $10 million to clean up surrounding environment on the Bryce grounds and restoration of the main hospital building, construction of which started in 1853 (La Fond & Dulham, 2002).
The state had explored other options to replace Bryce, including the possibility of renovating neighboring Birmingham facility and moving Bryce clients there.
Wyatt vs. Stickney lawsuit spanned 33 years. It was the longest running mental health lawsuit in the nation and it helped set standards of care, which have improved and boosted the lives of countless persons with mental illness and mental retardation (Yackle, 2004). Litigation costs to the state over the 33 year time span of the case were estimated at over 15 million dollars.
In the year 1970, there were over 8,000 patients in mental illness facilities and over 2,200 residents in mental retardation facilities. In addition, there were fewer than 15,000 persons from both populations who were receiving community based services (Springer, 2005). At present, over 110,000 people with either mental illness or mental retardation are served in community based care and fewer than 1,500 are in state institutions.
Implications of Wyatt vs. Stickney
This 1970 Alabama case resulted in recognition, for the first time, of the constitutional rights of mentally disabled patients living in state run psychiatric hospitals which were being jeopardized under the 14th Amendment. This case garnered overwhelming interests beyond the state of Alabama. The ruling forever transformed the way mental health services would be administered.
The Wyatt vs. Stickney lawsuit resulted in consideration and introduction of minimum standards for the care and rehabilitation of people with mental ailments and mental retardation. The case was a success since its determination ensured that patients with mental disabilities did not suffer from discrimination and inhuman conditions that they experienced before. Consequently, it brought to an end the sufferance of the mental patients.
Ten years after Federal Judge Frank M. Johnson gave the Wyatt vs. Stickney decision in 1972, the case was again scheduled for a hearing in January, 1983. Many of the issues which were in court the previous decade were again considered in the preceding hearing. The issues presently before the court included the motion for diversion of general fund and oil and gas funds to the Department of Mental Health, request for ending of the receivership under which the department presently operated, motion for declaration of the governor as receiver and appointment of a new receiver and fourth, motion for modification and the withdraw of the Wyatt standards to be substituted with other standards.
From the original ruling, significant changes occurred at both the national and state levels that in effect affected the outcome of Wyatt. The antecedents of this case were carefully scrutinized in order to understand the decision which will be arrived at. The decision that ultimately occurred in the Wyatt hearings of 1983 had a significant effect on services for the mentally retarded throughout the United States. They included:
1. No patient was to be subjected to any oppressive conditioning or other attempt to alter their behavior by means of painful experience, except under the following conditions:
a. A program for invasive conditions has been given by a qualified mental
health professional, trained and experienced in the use of aversive conditioning. This directive was to be made in writing with clinical justification and an explanation of which substitute treatments were considered and why they were rejected. The recommendation was to be supported by another qualified mental health professional trained and experienced in invasive conditioning and approved by the superintendent or medical director of the institution.
b. The patient has given expressed and informed consent in writing to the administration of the conditioning. It was the responsibility of the treating psychiatrist to provide the patient with full information concerning the nature of the invasive treatment, to assist the patient in understanding the significance of such information, and to consider and identify any barriers to such comprehension (Raskin, 2004). In addition, the written consent signed by the patient was to include a statement of the nature of the treatment consented to, a layout of its purpose, dangers and possible effects, and a notice to the patient that they have the right to withdraw their consent at any time.
2. No aversive conditioning was to be imposed or administered on any patient without the approval of the Extraordinary Treatment Committee, whose primary responsibility was to determine, after inquiry and interview with the patient, whether the patient’s consent to such therapy is, in fact, based on knowledge, intelligence, and voluntary and whether the treatment is in the interest of the patient (Springer, 2005).
3. The patient shall be represented throughout the proceedings including the signing of the consent and the meetings of the Extraordinary Treatment Committee, by legal counsel appointed by the Extraordinary Treatment Committee (Springer, 2005). The counsel was to ensure that all considerations mitigating the use of aversive conditioning have been explored and resolved and that the patient was ready to consent to such medical treatment.
4. Written records of consent and approval were to be kept.
5. Aversive conditioning procedures were to be administered only under direct supervision of and in physical presence of a qualified mental health professional trained in aversive conditioning (Yackle, 2004).
6. No patient was to be subjected to aversive conditioning program which attempts to alter socially appropriate behavior or to develop new behavior patterns for the primary purpose of institution (Yackle, 2004).
7. A patient was to withdraw their consent to aversive conditioning at any time and for any reason known to them. Such a withdrawal of consent was to be either oral or written and is to be effected immediately it is written.
In the lawsuit, some of the psychologists who were laid off were suing the Mental Health Department for their lost jobs and this can be described as another salient feature of the lawsuit. In spite of this, the intention of the plaintiffs to address the welfare of the mental patients was adequately adhered to during the lawsuit.
Many people felt and believed that Frank Johnson was the leader and champion in Alabama as the State leadership had proven time and again that they were not able to govern. The suit filed by the psychologists was lost at the Federal Level but allegedly as they were leaving the courtroom, Frank Johnson said that they were missing the critical point, what determines adequate care.