The Transformation of Treatment and Care for Persons with Mental Disabilities
News Flash! News Flash! December 5, 2003.
Federal Judge Myron Thompson, Jr. ended Wyatt vs. Stickney, the longest running mental health lawsuit in U.S. history. Commissioner Kathy Sawyer and Governor Bob Riley gave testimony in open hearing today and pledged to maintain the reforms and standards established by the 33-year Wyatt litigation. Judge Thompson used these words to describe the impact of the Wyatt case:
The enormity of what this case has accomplished cannot be overstated. The principles of humane treatment of people with mental illness and mental retardation embodied in this litigation have become part of the fabric of law in this country and, indeed, international law.
The Wyatt vs. Stickney suit was filed in October of 1970 on behalf of Ricky Wyatt, a patient at Bryce Hospital in Tuscaloosa, Alabama. Wyatt's aunt was a Bryce employee, facing a mass lay-off due to budgetary constraints. She and other mental health employees, including the mental health commissioner Dr. Stonewall Stickney himself, recognized the fact that lay-offs of professional staff would preclude even minimal treatment of patents at Bryce.
The case eventually assumed a "patients rights" posture and was transferred to Federal Court. In 1971, Federal Judge Frank Johnson, Jr. in Montgomery Alabama issued a landmark ruling that persons with mental disabilities had a constitutional right to personal treatment with minimum standards of care.
The words of Judge Johnson were as strong as the sounds of his court gavel. "There can be no legal or moral justification for the State of Alabama's failing to afford adequate treatment for persons committed to its care from a medical standpoint. Furthermore, 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."
Subsequently, the Judge identified 35 standards for adequate treatment for persons with mental disabilities in his order issued April 13, 1972. These standards included staffing, diet and nutrition, safety, physical plant adequacy, and many other features of protection. At the time of Judge Johnson's ruling, Bryce Hospital had over 5,000 patients with only 3 Psychiatrists. Partlow, the state's facility for persons with mental retardation had over 3,000 residents who also lived in overcrowded and inhumane conditions.
The question is; "How did it get this bad?" Why did Alabama and most other states allow these horrible conditions to exist?
Things were not always this bad. In fact, the early history of mental health in Alabama was characterized by the high moral and medical aspirations of mental health pioneers.
Cultural conditions in mid-nineteenth century America provided fertile soil for the development of a social conscience in the rising middle class. The pre-industrial agrarian society was rich in religion and had a strong altruistic motive to help those who were "less fortunate."
In particular, the Quakers rejected the harsh treatment of the disabled in Europe and called for more humane care for those they considered to be "mentally defective." This and other social transformations spawned the Moral Treatment Movement. One of the champions of the Moral Treatment Movement was Dorothea Dix.
In the late 1840's Miss Dix visited Alabama and lobbied the governor and the legislature for the establishment of a state hospital for the mentally disabled.
I first visited Alabama in the spring of 1847. I was fortunate to spend a productive day with Chief Justice Henry Collier. Little did I know that he would one day become governor. Two years later in his inaugural address to the Legislature, Governor Collier recommended the establishment of a state hospital for the insane. In 1861, nearly 12 years later, the hospital was completed. I've never had a prouder day in my life.
The hospital assumed the design of the Kirkbride model. Kirkbride was a world-renowned architect who conceptualized hospital facilities where every room had an outside window with views of spacious grounds. Dr. Peter Bryce was the first Superintendent of the hospital. His philosophy of patient care was extraordinarily progressive. He believed in freedom from seclusion and restraint and that every patient had the right to the latest forms of treatment and care.
In the early years of the hospital Dr Bryce wrote these words: I have abolished all mechanical restraints of a patient such as a strait jacket bed straps, crib beds and other restraining apparatus . The health, comfort and human custody of this unfortunate class of sufferers. Must receive the first and highest consideration of the employees of the institutions. There can be no higher or nobler work.
At the new facility meals were provided in dining room settings where patients could visit and enjoy the camaraderie of their friends. Patients had their own rooms furnished much like home. This atmosphere was worlds apart however from the conditions earlier in the 19th century that were experienced by the mentally disabled.
One writer put it like this:
Just a few years before the so-called "indigent insane and the "feebleminded" lived horrendous conditions and were often warehoused with the able-bodied poor and the orphans. Cages were among the popular forms of treatment. People were considered to be slightly more valuable than animals. In fact, animals were often treated better than this poor lot.
Bryce hospital was a giant step in the right direction in contrast to this picture. However, it would be another 60 years before a clear-cut distinction was made between the treatment of persons with mental illness and individuals with mental retardation. For those 60 years they all lived together at Bryce. Bryce had been established to offer peace and tranquility to the mentally disabled. In accordance with its mission the staff utilized the most modern forms of treatment known at this time.
One of the main forms of therapy for patients was farming. Annually, residents worked in the fields and reaped enough harvest to make the institution virtually self-sufficient. Some called this a "plantation" system and criticized hospitals for taking advantage of the mentally defective.
Admittedly, patients worked long hours in the fields with no pay. However, outside work was considered to be a form of therapy in the late 19th and early 20th centuries. The reformer Dorothea Dix supported the farm-therapy system as beneficial to the health and welfare of the patients. In Alabama, people with mental retardation worked side by side with people who were mentally ill and produced enough harvests to pay for the expenses of the hospital.
The second mental hospital built in the state was Searcy Hospital near Mobile, Alabama. The hospital was constructed on the property once occupied by a U.S. Army post. At one time, the post housed over 400 Apache Indians including the infamous chief Geronimo.
In 1895, the Post was given to the state of Alabama and in 1902 a hospital was built for the purpose of providing services for blacks. In consideration of the limited funds provided for the renovation of the Federal buildings, Dr. Reuben Searcy utilized Bryce patients to prefabricate the windows and other architectural features of the facility. Like Bryce, Searcy Hospital had an aggressive farm-therapy program and became virtually self-sufficient from the sale of produce.
From the turn of the Century through the great depression and World War II, the living conditions in these facilities deteriorated significantly. Organizations like the American Association for Mental Defectives emerged and emphasized the need for distinct services for persons with mental retardation and better living conditions for these individuals.
Dr. W.D. Partlow, who served as assistant superintendent for Bryce and Searcy hospitals, saw the need for an institution that would provide distinct services for people with mental retardation.
In 1922 the first buildings of what was then called "Alabama School for Mental Deficients" were completed on 108 acres of property adjoining the lands of Bryce Hospital in Tuscaloosa. In 1927 the legislature changed the name to honor Dr. Partlow.
The great boost to the program came with the organization of "Patrons for Partlow State School", an organization of relatives and friends who influenced the up-keep of the services of the school. Alabama was one of the early states to arouse and encourage lay interest in this manner.
Between 1930 and 1940 the census at Bryce grew from 2600 to over 4,000 people. Partlow's population also doubled. In the post World War II era admissions in Bryce and Partlow continued to soar as living conditions fell into what amounted to a "warehousing" system.
Although there were some advances in treatment and developmental techniques, living conditions were sadly similar to the horrible overcrowded and inhuman settings that were opposed by Dorothea Dix 100 years earlier.
The original visions of Dr. Bryce and Dr. Partlow to provide quality care in a quality environment had been swept away. People with mental retardation who were deemed to have "unmanageable behavior" continued to be commingled with the mentally ill patients at Bryce hospital through the 1960s.
In 1970 a journalist who visited the Jemison building which was part of Partlow described the conditions as follows: "Human feces was caked on the toilets and walls, urine saturated the aging oak floors, many beds lacked linen, some clients slept on floors, archaic shower stalls had cracked and spewing shower heads. One tiny shower closet served over131 male clients; the 75 women clients also had only one shower. Most of the clients at Jemison were highly tranquilized and had not even been bathed in days. All appeared to lack any semblance of treatment. The stench was almost unbearable."
Thus the downward spiral of warehousing overcame the aspirations of the early reformers... until... 1971 when Federal Judge Frank Johnson, Jr. issued his landmark ruling in the fledgling Wyatt vs. Stickney lawsuit. The ruling decreed that people with mental disabilities had a constitutional right to personal treatment with minimum standards of care. These standards included staffing, diet and nutrition, safety, physical plant adequacy, and many other features of protection.
At the time of Judge Johnson's ruling Bryce Hospital had only 3 Psychiatrists to serve over 5,000 patients. Discharge was virtually impossible without careful scrutiny by one of these Doctors. Partlow, the state's institution for persons with mental retardation, had over 3,000 residents living in overcrowded and inhumane conditions who had no legal alternative.
Wyatt vs. Stickney led to sweeping reforms in mental health systems in the state and ultimately across the nation. The first major reform in Alabama was the beginning of state funding for community programs for persons with mental retardation. Local chapters of the Association for Retarded Citizens were among the first providers.
A significant change occurred with the establishment of regional Developmental Centers for persons with mental retardation. In the early 70s, Lurleen B. Wallace, the wife of Governor George Wallace, visited Partlow in the early 70s and was struck with the horrendous living conditions at the facility. She asked the legislature to provide funding for other residential facilities that would provide developmental opportunities for people with mental retardation.
The first of these was the Lurleen B. Wallace Developmental Center named in her honor in Decatur, Alabama. In the early 70s the Wallace Center instituted state of the art services for residential and day habilitation. The J.S. Tarwater Developmental Center followed in 1977 along with A.P. Brewer Developmental Center in Mobile in 1984. The Glenn Ireland Developmental Center, established in Birmingham in 1986, was closed within a decade due to the downsizing initiatives of Wyatt. By the early 90's the state of Alabama had a growing community provider network and four Developmental Centers that provided institutional services for all geographic portions of the state.
Wyatt not only set minimum standards of care, but it also placed emphasis on the downsizing of state institutions and the proliferation of community services. The census at Partlow decreased from over 2200 in 1972 to less than 400 individuals in 1986. With the rise of community services the Developmental Centers were in a sense destined to work themselves out of a job. By the termination of Wyatt in 2003, all but one of the Centers was slated for closure. In 2004 the one that remained was the W.D. Partlow Center in Tuscaloosa.
The department now serves over 12,000 people a year with mental retardation through community contract providers and less than 300 annually at Partlow. In 2003, the department's Division for Mental Retardation Services opened the first Office of Consumer Empowerment. The Director of this Office is an individual with a cognitive developmental disability.
Many citizens with mental retardation are now active self-advocates. They exercise their right to vote, many are employed and a good number enjoy their own apartment. Others live in the community with various levels of support and enjoy the opportunities of community life with full inclusion.
In his brief written in association with the termination of Wyatt, Judge Myron Thompson, Jr. said;
Wyatt heightened public awareness of the needs of institutionalized people with mental illness or mental retardation. Today, as a result, any judge, legislator, or executive official who would seek to reverse the everyday involvement and oversight of state and local advocacy groups, friends and family members of people with mental disabilities, and self-advocacy by consumers, would face universal condemnation. Therefore, the legacy of this litigation cannot be terminated by any court.