Am
The
Right
BY EDWARD
to Treatment KAUFMAN,
Suit
as an
.
LEGAL CONCEPT of the individual’s right to treatment in psychiatric hospitals, prisons, and facilities for young people has grown in importance since its introduction in 1960. Recent right to treatment suits have generated controversy within psychiatry as to the value or harm of such legal actions. My intent in this article is to illustrate some positive values that may accrue from right to treatment suits, which serve as an agent of change in the structure and function of institutions. I recently evaluated five psychiatric institutions as an expert witness in right to treatment suits. In this article I will describe the circumstances and consequences of these evaluations and of the related legal suits and discuss the positive implications of such legal actions. I cannot name the specific hospitals because several of the suits are not yet totally resolved. THE
OF
RIGHT
TO
TREATMENT
SUITS
The concept of a patient’s constitutional right to treatment was first suggested by Birnbaum (1) in 1960. He stated that patients committed to a state mental hospital are constitutionally entitled to treatment. He envisioned suits to guarantee this right as a solution to the problem of worsening conditions in state hospitals. The first case to test this concept was Rouse v. Cameron (2) in 1966. Judge Bazelon ruled in this case that Presented Association, revised Oct.
at the
13 1st annual
Atlanta, 2, 1978;
Ga., May accepted
meeting 8-12, Feb.
of the American Psychiatric 1978. Received May 22, 1978; 16,
1979.
Dr. Kaufman is Associate Clinical Professor of Psychiatry and Human Behavior, University of California, Irvine, College of Medicine, and Chief, Psychiatric Services, University of California, Irvine, Medical Center, 101 City Drive South, Orange, Calif. 92668. The author acknowledges M.D., in the preparation
1428
/36:1/,
November
1979
of Change
M.D.
Right to treatment suits can serve as agents of change in the standards andfunction of psychiatric institutions The author evaluatedfive state psychiatric institutions as an expert witness in right to treatment suits. Hefound that changesfor the better were made in most ofthese institutions as a result of the suit, whether it was settled or unsettled. Although he enumerates the problems caused by such suits, he concludes that they can be a positiveforcefor improving mental health care.
HISTORY
Agent
J Psychiatry
the assistance of this paper.
of E.
0002-953X/79/12/1428/05/$00.50
Mansell
Pattison,
© 1979
not only was a right to treatment contained in the statutes of the District of Columbia, but the conditions in the hospital involved violated the Eighth Amendment’s prohibition against cruel and unusual punishment (3). Other important cases followed, particularly Nason v. Bridgewater (4), Wyatt v. Stickney (5),’ Donaldson V. O’Connor (6), and Dixon v. Weinberger (7). The Nason case confirmed the patient’s right to an individualized treatment program. In Wyatt v. Stickney, Judge Johnson established detailed standards of mental health care that would fulfill the patient’s constitutional right to treatment and that were not cruel and unusual punishment. In Donaldson v. O’Connor the Supreme Court ruled that mental illness alone cannot justify locking a person up against his or her will if the person is not dangerous to himself or others. In Dixon v. Weinberger it was ruled that committed patients have a statutory right to the least restrictive appropriate facility and that such facilities should be created if they do not exist.
STANDARD
OF
CARE
CRITERIA
I evaluated the five hospitals by comparing the patient care in them with the standards established by Wyatt v. Stickney (5). These standards emphasize a humane psychological and physical environment, an adequate number of qualified staff, and individualized treatment plans. According to Wyatt, important aspects ofa humane environment include 1) the patient’s right to privacy and dignity, 2) the right to the least restrictive conditions necessary, 3) the right to visitation, to use the telephone, and to send and receive sealed mail, 4) the right to be free from unnecessary physical restraint and isolation, 5) the right to informed consent and consultation before being subjected to experimental research or hazardous treatment procedures (e.g., lobotomy and adverse reinforcement), 6) the right to regular physical exercise, time outdoors, and socialization with the opposite sex, and 7) monetary compensation for therapeutic labor. The Wyatt criteria stipulate that physical facilities are to be designed to make a positive contribution to treatment goals, and that the number of people in a room should not exceed 6, with a minimum of 80
‘When Stonewall B. Stickney was discharged he was replaced by Charles L. Aderholt, who was also forced to resign after one year. The suit was renamed Wyatt v. Aderholt and then Wyatt v. Hardin. American
Psychiatric
Association
Am
J Psychiatry
136:11,
November
1979
square feet per person and screens to provide privacy. Standards were also established for toilet facilities, day room and dining space, temperature regulation, and nutrition. Judge Johnson’s ruling required the following numben of treatment personnel per 250 patients: 2 psychiatnists, 4 other physicians, 12 registered nurses, 6 licensed practical nurses, 92 aides, 4 psychologists, and so on. He set the total staff-patient ratio at 207.5:250. The Wyatt criteria also required that an individualized treatment plan be implemented for each patient no later than 5 days after admission. This plan is to include the nature of the patient’s specific problems and needs, intermediate and long-range goals and how to achieve them, and a specification ofthe staff responsibility and involvement needed to attain these goals.
HOSPITAL
EVALUATIONS
I evaluated two hospitals, hospital A and hospital B, in one southwestern state. These two hospitals were quite different from each other, and, despite serious deficiencies in both, the attributes of one emphasized the problems of the other. Hospital A had 500 patients housed in attractive, well-spaced buildings. The superintendent was a welltrained, Board-certified psychiatrist. Hospital B had 1 ,000 patients housed in dreary buildings. The superintendent’s only specialty training was in surgery. These basic facts contributed to the differences between the two hospitals. What they had in common was that they both had problems that required substantial changes. Hospital A had no psychiatrist providing clinical services. This most likely accounted for several problems at this hospital, including 1) the use of high doses of intramuscular chlonpromazine on a p.r.n. basis without monitoring of vital signs, 2) the lack of adequate maintenance doses of antipsychotic medication, 3) the use of seclusion as punishment, 4) the lack of integrated, individualized treatment plans, 5) the use of ECT without careful review, and 6) the lack of adequate professional leadership at the ward level. Hospital B’s problems were more widespread. The buildings did not provide for personal privacy. Polypharmacy was rampant, and drugs were often used inappropriately. Seclusion was used punitively and for prolonged periods of time without appropriate monitoring or reevaluation. There were serious staffing deficiencies according to the Wyatt standards. Particularly lacking were psychiatrists (28% of the standards) and physicians (14% of the standards). Wyatt standards are relatively low when compared with the staffing patterns of general hospital psychiatric units, Veterans Administration hospitals, and private mental hospitals (8): the average number of psychiatrists for 250 patients is 21 in general hospitals, 23 in private hospitals, and 7.5 in Veterans Administration mental units. Treatment plans at hospital B were not based on the patient’s psychosocial history and lacked long-
EDWARD
KAUFMAN
term goals, particularly planning for the patient after discharge from the hospital. The third hospital I evaluated, hospital C, is a maximum security mental hospital in the midwest. At this hospital I evaluated a form of therapy called ‘reality therapy,” which was used on two wards. Reality therapy, developed by William Glasser (9), has recently been adopted for use with psychotic patients. The basic principles of the therapy theoretically include patient-staff involvement, emphasis on current behavior, planning responsibility, accepting no excuses, and disciplining rather than punishing. Although these principles appear theoretically sound, they were grossly abused at hospital C. Many highly punitive and destructive practices were used and excused because they were called ‘reality therapy.” Physical restraints, particularly leather belts and cuffs that restrained a patient’s four limbs and waist to a bed, were used excessively and continuously without appropriate reevaluation (10). All patients were secluded for 24 hours at the time of admission to the ward. Although waist cuffs were used rarely, hand and leg cuffs were very common. Many patients had become dependent on wrist cuffs and kept them on for self-control long after staff felt this was necessary. When these patients developed sufficient self-control to function within their limited reality (e.g., to roll up their toilet paper, make their beds, and not strike others), they were permitted out of their cells for gradually increasing intervals, starting with 30 minutes in a sparsely equipped day room. Although the unit was designed for 2-3-month stays, most patients were there much longer. One reason for this was that patients were given no training in handling the responsibilities necessary for existence on less restrictive wards, let alone in a noninstitutional environment. The wards were run by paraprofessionals; input from anyone with more than a bachelor’s degree was almost nonexistent. The ward staffgenerally were pleased with “reality therapy’ because it gave them a system for restraining and dealing with patients that could be learned in a few short workshops. However, dissension caused by the inhumanity of this ‘reality therapy’ had led to the psychiatrists and psychologists leaving the wards. The remaining psychiatrist was never present on the ward but stated that he lent his name to whatever orders the staffsuggested as long as they were ‘in line. The two wards that used ‘reality therapy’ were highly coercive and restrictive in their physical planning and their treatment ofpatients. These wards met almost none of the standards of Wyatt, but I did not need these standards to evaluate the gross mistreatment of patients in these wards. The fourth hospital I evaluated, hospital D, is a large state hospital with more than 1,000 patients in a northeastern state. Here I limited my evaluation specifically to chemotherapy and psychotherapy. I asked the hospital to prepare a list of the number of patients in regularly scheduled individual and group psychotherapy ‘
‘
‘
‘
‘
‘
‘
“
‘
1429
RIGHT
TO
TREATMENT
with each therapist. There were no Board-certified psychiatrists working with adults at this hospital, and most of the psychiatrists here had caseloads of 100200 patients. Almost all of the psychotherapy at this hospital was conducted by psychologists, many of whom were foreign-trained; this created an insurmountable cultural and linguistic disparity between therapist and patient. One therapist, who led an intact continuing psychotherapy group, commented with a great deal of frustration that there was only one such group in operation in a section of more than 200 patients. The hospital was able to document that 20 patients were receiving regular individual psychotherapy. All ofthe therapists who were interviewed, including the psychiatrists, stated that they felt that much more psychotherapy was indicated but that they were unable to do it because of huge caseloads, other time demands, patient unavailability, and hospital bureaucracy. Polypharmacy was rampant at hospital D: exclusive of antiparkinsonian agents, 65% of the patients were receiving more than one psychotropic drug. However, much more striking was the fact that 60% of the patients had their dose set on the first day of hospitalization with no subsequent change throughout the duration of their hospitalization. The fifth hospital I evaluated, hospital E, is located in a western state. I evaluated this hospital on two separate visits at 3-month intervals. The maximum secunity unit at this hospital was decidedly superior to any unit in the other four hospitals. This hospital used the concept of the therapeutic community in a refined and advanced manner. Here disturbed patients learned to assume responsibility for themselves and their fellow patients. Thus, psychotic behavior was controlled and frequently reversed without the aid of undue physical or chemical restraints. During the first visit, I noted that the hospital was beginning to deteriorate because of budgetary cuts and the imminent removal, for political reasons, of the superintendent who had done so much to create a thempeutic atmosphere. A nonpsychiatrist administrator was to replace him. By the second visit, I noted a dedine in excellence. The therapeutic milieu was compromised to a point where difficult patients were not admitted and the ward was threatened with closure. Intramuscular chlorpromazine was used frequently on a p.r.n. basis and at higher doses than I observed duning the first visit. Verbal orders had not been countersigned for the preceding 10-day period. However, there was optimism among the staff that budget cuts would be reversed and that the ward would cycle back to its previous state. A trend that I observed in all five of the state hospitals I visited was a de-emphasis of the role of the psychiatrist, particularly as team leader. Many psychiatrists reacted to this trend by withdrawing from the team except to perform minimal functions or by resigning. The replacement of the psychiatrist superintendent at hospital E with a nonphysician administi-aton may also be reflective of this trend. 1430
Am
SUIT
J Psychiatry
136:11,
November
1979
All five hospitals were generally inadequate in structure and function. There was insufficient impetus to change these conditions before the implementation of right to treatment suits. It is doubtful that these grossly inadequate treatment programs would have improved or changed without some legal action.
POSITIVE
EFFECTS
OF
RIGHT
TO
TREATMENT
SUITS
Detailed reports evaluating the extent to which patients’ constitutional rights to treatment were violated by the care at these hospitals have been submitted to thejudiciary. The suit involving hospitals A and B has not been settled. However, the legislature of that state has allocated a considerable increase in funds to its state hospitals. ‘Reality therapy’ has been totally stopped, at least in name, at hospital C, and a monitor has been appointed to see that court recommendations are enforced there. The settlement of the suit at hospital D specified that 1) patients shall be protected from physical harm, 2) ECT shall not be administered without informed consent, 3) individual and personal civil rights will be afforded, 4) physical facilities will provide safety, dignity, and privacy, 5) patients shall have the right to the least restrictive conditions necessary to achieve the purposes of treatments and 6) all patients shall have the right to a humane psychological and physical environment. The implementation of these rights, standards, and services is overseen by a sevenmember committee that includes a former patient at the hospital and two mental health professionals. These four hospitals are all advertising aggressively for new psychiatrists, and many new psychiatrists have arrived recently at hospital D. My experience at hospital E was quite different from that at the other four institutions. Here a program existed that provided adequate treatment without restrictive and inhumane conditions. At thetime of my inspection this program was seriously threatened by funding cuts and administrative shifts. As a result of the right to treatment suit, the state conducted its own inspection of the hospital using the staff of the local university college of medicine. As a result of this inspection many defects were given the needed publicity to ensure the appropriations necessary to correct existing problems and continue adequate programs. Thus, the right to treatment suit in this setting helped provide the funding necessary to prevent the deterioration of an excellent program. The Wyatt decision has resulted in many positive changes in Alabama. In 1972, the year ofthat decision, $6.50 per day was the average spent on each patient in institutions for the mentally ill. According to Judge Johnson (11), that figure is now eight times greater. The staff-patient ratio was .47:1 for 8,000 patients in 4 facilities. There are now 4,000 patients in 10 facilities with a staff-patient ratio of 1.4:1 (11). The quality of care in these institutions in Alabama has improved, ‘
‘
Am
J Psychiatry
136:11,
November
/979
EDWARD
but, according to Judge Johnson (1 1), full compliance with Wyatt standards ‘has not been attained.” ‘
PROBLEMS
WITH
RIGHT
TO
TREATMENT
KAUFMAN
However, even these measures will not be enough unless they are implemented in a way that considers and alleviates those forces within state hospitals which inherently resist change (16).
SUITS
Although right to treatment suits have resulted in substantial changes, they have also created many problems. Psychiatrists who are working in good faith in institutions with limited resources may be sued for monetary damages (12). Some ofthe negative publicity about the inadequacy of state hospitals has damaged leaders of proven excellence in the mental health field. Thus, these suits have driven away those psychiatrists who have worked hard toward positive changes in these institutions. There are other problems as well. These suits permit attorneys and judges rather than psychiatrists to set standards for mental health care. Even if the suits are won, there is a strong possibility that funds will not be made available to enact their recommendations, or, if money is made available, it may be at the expense of other equally worthy mental health causes. Pouring money into large, poorly run institutions perpetuates them; they should be dismantled in favor of smaller, community-based institutions. Even when additional funding is made available, the difficulties in recruiting well-trained staff for such institutions are substantial. If staff-patient ratios and quantity of specific types of staffare dictated by legal restraints, treatment flexibility could be severely limited. Right to treatment suits also add one more force impinging on patient care to the already burgeoning list of regulatory agencies (13), and the demands of these suits add to the rapidly increasing burden of paperwork (13). They also add to the threats of political investigation that prevent workens from pursuing their careers nondefensively (14). They may make research difficult, if not impossible. The right to adequate compensation for therapeutic work by patients has resulted in a marked diminution in the number of patients assigned to potentially rehabilitative tasks in all five of the state hospitals I evaluated. At hospital B the number of patients so employed since the implementation of their right to compensation dropped from 200 to none for more than a year until funds were allocated for patient employment. At the time of my evaluation, 30 patients were employed at rates ranging from $.25 to $1.75 an hour. Thus, steps have been taken to right the wrongs created by legislation; if properly implemented with full funding, these steps will be to the ultimate advantage of patients. There is no guarantee that court-mandated changes will be made. Mechanisms to ensure that they will be made have included continued access to grounds and records by the plaintiffs attorneys, ombudsmen and lay advocates, human rights committees, review panels, and special masters with broad powers to evaluate compliance and, when necessary, take over responsibility for implementing the order of the court (15).
CONCLUSIONS
The legal profession’s setting of standards for mental health care is fraught with difficulty. However, according to Kopolow (13), the conditions in many state hospitals over the past century have ‘warranted the public demands for increased accountability and judicial purview. More specifically, the conditions at the five hospitals described here before my evaluations ranged from a need for minimal improvements to gross inhumanities. The changes that have been made since right to treatment suits have been initiated have resulted in improvements in these and other state hospitals. These suits will continue to play an important role in creating further needed changes. Recognizing the potential helpful role of right to treatment suits, the staff psychiatrists employed at a California state hospital recently implemented such a suit on their own to better conditions in their institution. I hope that most if not all institutional psychiatrists will become less defensive about such suits and will use them to further their own program goals (17). So many other events have occurred that it is difficult to attribute these results directly to right to treatment suits. However, I think that these suits, whether settled or unsettled, have been an important step in establishing adequate standards of care and the resources to provide them. ‘
‘ ‘
REFERENCES 1. Birnbaum M: The right to treatment. American Bar Association Journal 46:499-505, 1960 2. Rouse v Cameron, 373 F 2d 451 (DC Cir 1966) 3. Stone AA: Overview: the right to treatment-comments on the law and its impact. Am J Psychiatry 132:1125-1134, 1975 4. Nason v Superintendent of Bridgewater State Hospital, 233 NE 2nd 908 (Mass 1968) S. Wyatt v Stickney, 344 F Supp 373, 373-386 (MD Ala 1972) 6. Donaldson v O’Connor, 493 F 2d 507, 520 (5th Cir 1974) 7. Dixon v Weinberger, 405 F Supp 974 (D DC 1975) 8.
Taube
CA,
Witken
JM:
StaffPatient
Ratios
in Selected
Inpatient
Mental Health Facilities, January 1974. Mental Health Statistical Note 129. US Department of Health, Education, and Welfare Publication 76-158. Washington, DC, US Government Printing Office, 1976 9. Glasser W: Reality Therapy, A New Approach to Psychiatry. New
York,
10. Rosen treatment 38:228-232,
Harper
H. DiGiacomo of
psychiatric 1977
& Row,
JN:
1975
The illness.
role
of physical
Journal
restraint
of Clinical
in the
Psychiatry
11. Johnson defends judicial activism. Psychiatric News, April 7, 1978, pp 1, 27,29 12. McGarry AL: The holy legal war against state-hospital psychiatry. N EngI J Med 294:318-320, 1976 13. Kopolow LE: Patients’ rights and the psychiatrist’s dilemma. Bull Am Acad Psychiatry Law 4:197-203, 1976 14. Greenblatt M: The need for balancing the right to treatment and 1431
RIGHT
TO
TREATMENT
the right to treat. Hosp Community Psychiatry 28:382-383, 1977 IS. Cottman MS: Enforcement of judicial decrees: now comes the hard part. Mental Health Disability Law Reporter July-August 1976, pp 69-76
1432
Am
SUIT
16. Fowlkes Psychiatry 17.
Macht
atric
J Psychiatry
MR: Business as usual 38:55-64, 1975 LB:
Opinion
Commissioner:
15:1133-1135,
a special
1978
136:11,
at the
state
clinical
November
1979
mental
hospitals.
executive.
Psychi-
The
Right
BY EDWARD
to Treatment KAUFMAN,
Suit
as an
.
LEGAL CONCEPT of the individual’s right to treatment in psychiatric hospitals, prisons, and facilities for young people has grown in importance since its introduction in 1960. Recent right to treatment suits have generated controversy within psychiatry as to the value or harm of such legal actions. My intent in this article is to illustrate some positive values that may accrue from right to treatment suits, which serve as an agent of change in the structure and function of institutions. I recently evaluated five psychiatric institutions as an expert witness in right to treatment suits. In this article I will describe the circumstances and consequences of these evaluations and of the related legal suits and discuss the positive implications of such legal actions. I cannot name the specific hospitals because several of the suits are not yet totally resolved. THE
OF
RIGHT
TO
TREATMENT
SUITS
The concept of a patient’s constitutional right to treatment was first suggested by Birnbaum (1) in 1960. He stated that patients committed to a state mental hospital are constitutionally entitled to treatment. He envisioned suits to guarantee this right as a solution to the problem of worsening conditions in state hospitals. The first case to test this concept was Rouse v. Cameron (2) in 1966. Judge Bazelon ruled in this case that Presented Association, revised Oct.
at the
13 1st annual
Atlanta, 2, 1978;
Ga., May accepted
meeting 8-12, Feb.
of the American Psychiatric 1978. Received May 22, 1978; 16,
1979.
Dr. Kaufman is Associate Clinical Professor of Psychiatry and Human Behavior, University of California, Irvine, College of Medicine, and Chief, Psychiatric Services, University of California, Irvine, Medical Center, 101 City Drive South, Orange, Calif. 92668. The author acknowledges M.D., in the preparation
1428
/36:1/,
November
1979
of Change
M.D.
Right to treatment suits can serve as agents of change in the standards andfunction of psychiatric institutions The author evaluatedfive state psychiatric institutions as an expert witness in right to treatment suits. Hefound that changesfor the better were made in most ofthese institutions as a result of the suit, whether it was settled or unsettled. Although he enumerates the problems caused by such suits, he concludes that they can be a positiveforcefor improving mental health care.
HISTORY
Agent
J Psychiatry
the assistance of this paper.
of E.
0002-953X/79/12/1428/05/$00.50
Mansell
Pattison,
© 1979
not only was a right to treatment contained in the statutes of the District of Columbia, but the conditions in the hospital involved violated the Eighth Amendment’s prohibition against cruel and unusual punishment (3). Other important cases followed, particularly Nason v. Bridgewater (4), Wyatt v. Stickney (5),’ Donaldson V. O’Connor (6), and Dixon v. Weinberger (7). The Nason case confirmed the patient’s right to an individualized treatment program. In Wyatt v. Stickney, Judge Johnson established detailed standards of mental health care that would fulfill the patient’s constitutional right to treatment and that were not cruel and unusual punishment. In Donaldson v. O’Connor the Supreme Court ruled that mental illness alone cannot justify locking a person up against his or her will if the person is not dangerous to himself or others. In Dixon v. Weinberger it was ruled that committed patients have a statutory right to the least restrictive appropriate facility and that such facilities should be created if they do not exist.
STANDARD
OF
CARE
CRITERIA
I evaluated the five hospitals by comparing the patient care in them with the standards established by Wyatt v. Stickney (5). These standards emphasize a humane psychological and physical environment, an adequate number of qualified staff, and individualized treatment plans. According to Wyatt, important aspects ofa humane environment include 1) the patient’s right to privacy and dignity, 2) the right to the least restrictive conditions necessary, 3) the right to visitation, to use the telephone, and to send and receive sealed mail, 4) the right to be free from unnecessary physical restraint and isolation, 5) the right to informed consent and consultation before being subjected to experimental research or hazardous treatment procedures (e.g., lobotomy and adverse reinforcement), 6) the right to regular physical exercise, time outdoors, and socialization with the opposite sex, and 7) monetary compensation for therapeutic labor. The Wyatt criteria stipulate that physical facilities are to be designed to make a positive contribution to treatment goals, and that the number of people in a room should not exceed 6, with a minimum of 80
‘When Stonewall B. Stickney was discharged he was replaced by Charles L. Aderholt, who was also forced to resign after one year. The suit was renamed Wyatt v. Aderholt and then Wyatt v. Hardin. American
Psychiatric
Association
Am
J Psychiatry
136:11,
November
1979
square feet per person and screens to provide privacy. Standards were also established for toilet facilities, day room and dining space, temperature regulation, and nutrition. Judge Johnson’s ruling required the following numben of treatment personnel per 250 patients: 2 psychiatnists, 4 other physicians, 12 registered nurses, 6 licensed practical nurses, 92 aides, 4 psychologists, and so on. He set the total staff-patient ratio at 207.5:250. The Wyatt criteria also required that an individualized treatment plan be implemented for each patient no later than 5 days after admission. This plan is to include the nature of the patient’s specific problems and needs, intermediate and long-range goals and how to achieve them, and a specification ofthe staff responsibility and involvement needed to attain these goals.
HOSPITAL
EVALUATIONS
I evaluated two hospitals, hospital A and hospital B, in one southwestern state. These two hospitals were quite different from each other, and, despite serious deficiencies in both, the attributes of one emphasized the problems of the other. Hospital A had 500 patients housed in attractive, well-spaced buildings. The superintendent was a welltrained, Board-certified psychiatrist. Hospital B had 1 ,000 patients housed in dreary buildings. The superintendent’s only specialty training was in surgery. These basic facts contributed to the differences between the two hospitals. What they had in common was that they both had problems that required substantial changes. Hospital A had no psychiatrist providing clinical services. This most likely accounted for several problems at this hospital, including 1) the use of high doses of intramuscular chlonpromazine on a p.r.n. basis without monitoring of vital signs, 2) the lack of adequate maintenance doses of antipsychotic medication, 3) the use of seclusion as punishment, 4) the lack of integrated, individualized treatment plans, 5) the use of ECT without careful review, and 6) the lack of adequate professional leadership at the ward level. Hospital B’s problems were more widespread. The buildings did not provide for personal privacy. Polypharmacy was rampant, and drugs were often used inappropriately. Seclusion was used punitively and for prolonged periods of time without appropriate monitoring or reevaluation. There were serious staffing deficiencies according to the Wyatt standards. Particularly lacking were psychiatrists (28% of the standards) and physicians (14% of the standards). Wyatt standards are relatively low when compared with the staffing patterns of general hospital psychiatric units, Veterans Administration hospitals, and private mental hospitals (8): the average number of psychiatrists for 250 patients is 21 in general hospitals, 23 in private hospitals, and 7.5 in Veterans Administration mental units. Treatment plans at hospital B were not based on the patient’s psychosocial history and lacked long-
EDWARD
KAUFMAN
term goals, particularly planning for the patient after discharge from the hospital. The third hospital I evaluated, hospital C, is a maximum security mental hospital in the midwest. At this hospital I evaluated a form of therapy called ‘reality therapy,” which was used on two wards. Reality therapy, developed by William Glasser (9), has recently been adopted for use with psychotic patients. The basic principles of the therapy theoretically include patient-staff involvement, emphasis on current behavior, planning responsibility, accepting no excuses, and disciplining rather than punishing. Although these principles appear theoretically sound, they were grossly abused at hospital C. Many highly punitive and destructive practices were used and excused because they were called ‘reality therapy.” Physical restraints, particularly leather belts and cuffs that restrained a patient’s four limbs and waist to a bed, were used excessively and continuously without appropriate reevaluation (10). All patients were secluded for 24 hours at the time of admission to the ward. Although waist cuffs were used rarely, hand and leg cuffs were very common. Many patients had become dependent on wrist cuffs and kept them on for self-control long after staff felt this was necessary. When these patients developed sufficient self-control to function within their limited reality (e.g., to roll up their toilet paper, make their beds, and not strike others), they were permitted out of their cells for gradually increasing intervals, starting with 30 minutes in a sparsely equipped day room. Although the unit was designed for 2-3-month stays, most patients were there much longer. One reason for this was that patients were given no training in handling the responsibilities necessary for existence on less restrictive wards, let alone in a noninstitutional environment. The wards were run by paraprofessionals; input from anyone with more than a bachelor’s degree was almost nonexistent. The ward staffgenerally were pleased with “reality therapy’ because it gave them a system for restraining and dealing with patients that could be learned in a few short workshops. However, dissension caused by the inhumanity of this ‘reality therapy’ had led to the psychiatrists and psychologists leaving the wards. The remaining psychiatrist was never present on the ward but stated that he lent his name to whatever orders the staffsuggested as long as they were ‘in line. The two wards that used ‘reality therapy’ were highly coercive and restrictive in their physical planning and their treatment ofpatients. These wards met almost none of the standards of Wyatt, but I did not need these standards to evaluate the gross mistreatment of patients in these wards. The fourth hospital I evaluated, hospital D, is a large state hospital with more than 1,000 patients in a northeastern state. Here I limited my evaluation specifically to chemotherapy and psychotherapy. I asked the hospital to prepare a list of the number of patients in regularly scheduled individual and group psychotherapy ‘
‘
‘
‘
‘
‘
‘
“
‘
1429
RIGHT
TO
TREATMENT
with each therapist. There were no Board-certified psychiatrists working with adults at this hospital, and most of the psychiatrists here had caseloads of 100200 patients. Almost all of the psychotherapy at this hospital was conducted by psychologists, many of whom were foreign-trained; this created an insurmountable cultural and linguistic disparity between therapist and patient. One therapist, who led an intact continuing psychotherapy group, commented with a great deal of frustration that there was only one such group in operation in a section of more than 200 patients. The hospital was able to document that 20 patients were receiving regular individual psychotherapy. All ofthe therapists who were interviewed, including the psychiatrists, stated that they felt that much more psychotherapy was indicated but that they were unable to do it because of huge caseloads, other time demands, patient unavailability, and hospital bureaucracy. Polypharmacy was rampant at hospital D: exclusive of antiparkinsonian agents, 65% of the patients were receiving more than one psychotropic drug. However, much more striking was the fact that 60% of the patients had their dose set on the first day of hospitalization with no subsequent change throughout the duration of their hospitalization. The fifth hospital I evaluated, hospital E, is located in a western state. I evaluated this hospital on two separate visits at 3-month intervals. The maximum secunity unit at this hospital was decidedly superior to any unit in the other four hospitals. This hospital used the concept of the therapeutic community in a refined and advanced manner. Here disturbed patients learned to assume responsibility for themselves and their fellow patients. Thus, psychotic behavior was controlled and frequently reversed without the aid of undue physical or chemical restraints. During the first visit, I noted that the hospital was beginning to deteriorate because of budgetary cuts and the imminent removal, for political reasons, of the superintendent who had done so much to create a thempeutic atmosphere. A nonpsychiatrist administrator was to replace him. By the second visit, I noted a dedine in excellence. The therapeutic milieu was compromised to a point where difficult patients were not admitted and the ward was threatened with closure. Intramuscular chlorpromazine was used frequently on a p.r.n. basis and at higher doses than I observed duning the first visit. Verbal orders had not been countersigned for the preceding 10-day period. However, there was optimism among the staff that budget cuts would be reversed and that the ward would cycle back to its previous state. A trend that I observed in all five of the state hospitals I visited was a de-emphasis of the role of the psychiatrist, particularly as team leader. Many psychiatrists reacted to this trend by withdrawing from the team except to perform minimal functions or by resigning. The replacement of the psychiatrist superintendent at hospital E with a nonphysician administi-aton may also be reflective of this trend. 1430
Am
SUIT
J Psychiatry
136:11,
November
1979
All five hospitals were generally inadequate in structure and function. There was insufficient impetus to change these conditions before the implementation of right to treatment suits. It is doubtful that these grossly inadequate treatment programs would have improved or changed without some legal action.
POSITIVE
EFFECTS
OF
RIGHT
TO
TREATMENT
SUITS
Detailed reports evaluating the extent to which patients’ constitutional rights to treatment were violated by the care at these hospitals have been submitted to thejudiciary. The suit involving hospitals A and B has not been settled. However, the legislature of that state has allocated a considerable increase in funds to its state hospitals. ‘Reality therapy’ has been totally stopped, at least in name, at hospital C, and a monitor has been appointed to see that court recommendations are enforced there. The settlement of the suit at hospital D specified that 1) patients shall be protected from physical harm, 2) ECT shall not be administered without informed consent, 3) individual and personal civil rights will be afforded, 4) physical facilities will provide safety, dignity, and privacy, 5) patients shall have the right to the least restrictive conditions necessary to achieve the purposes of treatments and 6) all patients shall have the right to a humane psychological and physical environment. The implementation of these rights, standards, and services is overseen by a sevenmember committee that includes a former patient at the hospital and two mental health professionals. These four hospitals are all advertising aggressively for new psychiatrists, and many new psychiatrists have arrived recently at hospital D. My experience at hospital E was quite different from that at the other four institutions. Here a program existed that provided adequate treatment without restrictive and inhumane conditions. At thetime of my inspection this program was seriously threatened by funding cuts and administrative shifts. As a result of the right to treatment suit, the state conducted its own inspection of the hospital using the staff of the local university college of medicine. As a result of this inspection many defects were given the needed publicity to ensure the appropriations necessary to correct existing problems and continue adequate programs. Thus, the right to treatment suit in this setting helped provide the funding necessary to prevent the deterioration of an excellent program. The Wyatt decision has resulted in many positive changes in Alabama. In 1972, the year ofthat decision, $6.50 per day was the average spent on each patient in institutions for the mentally ill. According to Judge Johnson (11), that figure is now eight times greater. The staff-patient ratio was .47:1 for 8,000 patients in 4 facilities. There are now 4,000 patients in 10 facilities with a staff-patient ratio of 1.4:1 (11). The quality of care in these institutions in Alabama has improved, ‘
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but, according to Judge Johnson (1 1), full compliance with Wyatt standards ‘has not been attained.” ‘
PROBLEMS
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KAUFMAN
However, even these measures will not be enough unless they are implemented in a way that considers and alleviates those forces within state hospitals which inherently resist change (16).
SUITS
Although right to treatment suits have resulted in substantial changes, they have also created many problems. Psychiatrists who are working in good faith in institutions with limited resources may be sued for monetary damages (12). Some ofthe negative publicity about the inadequacy of state hospitals has damaged leaders of proven excellence in the mental health field. Thus, these suits have driven away those psychiatrists who have worked hard toward positive changes in these institutions. There are other problems as well. These suits permit attorneys and judges rather than psychiatrists to set standards for mental health care. Even if the suits are won, there is a strong possibility that funds will not be made available to enact their recommendations, or, if money is made available, it may be at the expense of other equally worthy mental health causes. Pouring money into large, poorly run institutions perpetuates them; they should be dismantled in favor of smaller, community-based institutions. Even when additional funding is made available, the difficulties in recruiting well-trained staff for such institutions are substantial. If staff-patient ratios and quantity of specific types of staffare dictated by legal restraints, treatment flexibility could be severely limited. Right to treatment suits also add one more force impinging on patient care to the already burgeoning list of regulatory agencies (13), and the demands of these suits add to the rapidly increasing burden of paperwork (13). They also add to the threats of political investigation that prevent workens from pursuing their careers nondefensively (14). They may make research difficult, if not impossible. The right to adequate compensation for therapeutic work by patients has resulted in a marked diminution in the number of patients assigned to potentially rehabilitative tasks in all five of the state hospitals I evaluated. At hospital B the number of patients so employed since the implementation of their right to compensation dropped from 200 to none for more than a year until funds were allocated for patient employment. At the time of my evaluation, 30 patients were employed at rates ranging from $.25 to $1.75 an hour. Thus, steps have been taken to right the wrongs created by legislation; if properly implemented with full funding, these steps will be to the ultimate advantage of patients. There is no guarantee that court-mandated changes will be made. Mechanisms to ensure that they will be made have included continued access to grounds and records by the plaintiffs attorneys, ombudsmen and lay advocates, human rights committees, review panels, and special masters with broad powers to evaluate compliance and, when necessary, take over responsibility for implementing the order of the court (15).
CONCLUSIONS
The legal profession’s setting of standards for mental health care is fraught with difficulty. However, according to Kopolow (13), the conditions in many state hospitals over the past century have ‘warranted the public demands for increased accountability and judicial purview. More specifically, the conditions at the five hospitals described here before my evaluations ranged from a need for minimal improvements to gross inhumanities. The changes that have been made since right to treatment suits have been initiated have resulted in improvements in these and other state hospitals. These suits will continue to play an important role in creating further needed changes. Recognizing the potential helpful role of right to treatment suits, the staff psychiatrists employed at a California state hospital recently implemented such a suit on their own to better conditions in their institution. I hope that most if not all institutional psychiatrists will become less defensive about such suits and will use them to further their own program goals (17). So many other events have occurred that it is difficult to attribute these results directly to right to treatment suits. However, I think that these suits, whether settled or unsettled, have been an important step in establishing adequate standards of care and the resources to provide them. ‘
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REFERENCES 1. Birnbaum M: The right to treatment. American Bar Association Journal 46:499-505, 1960 2. Rouse v Cameron, 373 F 2d 451 (DC Cir 1966) 3. Stone AA: Overview: the right to treatment-comments on the law and its impact. Am J Psychiatry 132:1125-1134, 1975 4. Nason v Superintendent of Bridgewater State Hospital, 233 NE 2nd 908 (Mass 1968) S. Wyatt v Stickney, 344 F Supp 373, 373-386 (MD Ala 1972) 6. Donaldson v O’Connor, 493 F 2d 507, 520 (5th Cir 1974) 7. Dixon v Weinberger, 405 F Supp 974 (D DC 1975) 8.
Taube
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Mental Health Facilities, January 1974. Mental Health Statistical Note 129. US Department of Health, Education, and Welfare Publication 76-158. Washington, DC, US Government Printing Office, 1976 9. Glasser W: Reality Therapy, A New Approach to Psychiatry. New
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the right to treat. Hosp Community Psychiatry 28:382-383, 1977 IS. Cottman MS: Enforcement of judicial decrees: now comes the hard part. Mental Health Disability Law Reporter July-August 1976, pp 69-76
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