Three decades after advocates for the mentally ill filed a precedent-setting class-action suit over the sorry state of care in Alabama’s psychiatric hospitals, a settlement has been reached that promises to bring closure to the long, and ultimately successful, struggle.

The suit, originally known as Wyatt v. Stickney and most recently as Wyatt v. Sawyer, was filed to try to force the state of Alabama to guarantee that patients in its psychiatric hospitals would not be forced to endure inadequate or absent care as a result of a severe understaffing at state psychiatric hospitals. It ended in the first court decision that upheld committed patients’ constitutional right to psychiatric care.

The suit was filed in 1970 against the state over conditions at Bryce Hospital, a psychiatric facility in Tuscaloosa. At the time of the filing, the state had imposed severe staffing reductions at Bryce and other state hospitals, which it attributed to cuts in the state’s cigarette tax that led to a serious budget shortfall.

There was one psychiatrist for Bryce’s 5,000 patients after the cuts, with an equally troubling ratio of psychologists and social workers. (Today there are 600 patients living at Bryce.) The state budgeted about 50 cents a day for food, and the physical plants were in dire need of repair.

Ricky Wyatt, whose name the suit bears, was a patient at Bryce Hospital at the time the state imposed major staff layoffs. He was also the nephew of one of the dismissed workers. Stonewall B. Stickney, M.D., was mental health commissioner of Alabama at the time the suit was filed.

Attorneys who specialized in mental health treatment advocacy spearheaded the class-action suit. In 1972 their arguments convinced Federal District Court Judge Frank M. Johnson to decide in their clients’ favor. Johnson handed down the landmark ruling that involuntarily committed psychiatric patients have a constitutional right to adequate treatment and that the federal judiciary has the right to intervene when the state fails in its duty to provide such treatment to patients in its care.

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

But Johnson went much further than handing down a ruling. After consulting with individual experts and mental health organizations, including APA, he also issued specific standards the state had to meet to prove it was fulfilling its obligation to these patients. These included minimum staffing ratios, the obligation to develop a treatment plan for each patient, nutritional standards, and a least-restrictive-alternative standard. It even extended to how often linen had to be changed, how many toilets had to be available, and what steps needed to be taken to ensure patient hygiene.

"The detailed requirements for improved conditions of hospitalization that were promulgated by Judge Johnson set the standard for many subsequent court decisions, consent decrees, and regulations in states across the country," pointed out Paul Appelbaum, M.D., chair of the department of psychiatry at the University of Massachusetts Medical School and director of its Law and Psychiatry Program and an APA vice president.

Johnson ordered the state to implement the steps required to ensure adequate treatment at Bryce within six months, a goal the hospital did not come close to meeting.

Johnson spent the following years battling with the state’s governors and mental health commissioners over implementation of his orders and his right even to order such a comprehensive solution to a state problem.

"As was true in many right-to-treatment decisions, it turned out to be easier to order improvements in state systems than to implement them," Appelbaum explained. "The Alabama legislature was resistant to appropriating sufficient funds, and the executive branch was not always willing to spend existing funds in the ways specified by the courts. Indeed, it’s not clear that Alabama ever came fully into compliance with the original decree."

By 1977, with treatment standards still lagging, the plaintiffs went back to federal court and convinced it to assign monitors to assess the state’s continued compliance with Johnson’s orders. Nine years later, with full compliance still a distant goal, federal and state officials agreed to a settlement in which the federal government would terminate the court monitor program in return for a guarantee from Alabama officials that they would increase the money they spent on bringing state hospitals up to the standards ordered by Johnson.

The January 2000 settlement, which emphasizes that its implementation is to be "accomplished in a spirit of cooperation rather than an adversarial process," says that the state mental health commissioner and the governor will "apply their diligent, determined, and best efforts" to ensure that the legislature appropriates adequate funds to meet the obligations outlined by Judge Johnson. It also commits all parties to cooperate in developing within six months a statewide plan designed to educate the public about "the abilities, rights, and needs of persons with mental illness and mental retardation. . . ."

In addition, the defendants agree to maintain the minimal standards the ruling laid out for the provision of adequate treatment and to monitor the quality of treatment delivered to the mentally ill and mentally retarded individuals in the state’s care.

On treatment-specific issues, the settlement calls for the state to continue "to conduct interdisciplinary team meetings and to develop individualized treatment plans for each person residing" at the state’s remaining psychiatric hospitals. Staff will conduct monthly assessments of each person’s individualized program. Also, state hospital officials are given nine months to hire consultants who will develop recommendations on seclusion and restraint practices, the use of psychiatric medications including the involvement of parents and guardians in decision making, and discharge procedures.

To ensure that deinstitutionalization decisions are criteria based, the state agrees that by December 1, it will have developed a three-year plan for placing former inpatients in community settings. The settlement stresses that these "alternative placements and services shall be established before [a resident] is discharged" from a state facility.

Attorney Ira Burnim, who represented the plaintiffs from 1985 to 1999—a period during which the litigation focused on creating programs to allow mentally disabled Alabamans to live in community settings—noted that the settlement reached in January will move 600 more patients from hospitals to community facilities.

"We are especially heartened that Alabama, like many other states, will continue expanding possibilities for people with mental disabilities to have normal lives," said Burnim, who is now legal director of the Bazelon Center for Mental Health Law in Washington, D.C.

(Settlement agreement: Wyatt v. Sawyer, civ. action No. 70-T-3195-N, U.S. District Court, Middle District of Alabama, Northern Division.)