Wyatt vs. Stickney: The Rights of the Mentally Disabled
TALKING WITH STANLEY WEINSTEIN
The importance of Wyatt-Stickney became clear when Dr. Weinstein headed a federal grant project that eventually led to staffing standards for the state of Maryland.
“I was at the MHA when Wyatt-Stickney was really targeted towards implementation. In my position there I met with people from other states. The ramifications that came out of Wyatt-Stickney became an issue for most states, because Judge Johnson’s decisions from a federal court had implications for every state. Even now you think back that it was only 30 years ago that someone said involuntary committed patients have a right to treatment. It seems surprising that all those other years before that, what was going on? I truly began to know about the law and have it affect what I did, because one of the results of the case was staffing issues; setting minimum standards. That was the focus in part of what I was doing for the MHA. As a matter of fact we developed the set of staffing standards for the state of Maryland that were different than Wyatt-Stickney.”
Wyatt-Stickney significantly changed the delivery of mental health services.
“It is almost like looking at the history of mental health. We know that Wyatt-Stickney made dramatic changes in the way mental health services were delivered, often to the most seriously ill. It was the right to treatment. It was the concept of treatment in the least restrictive setting. It was staffing standards for quality. It meant safe environments; it talked about privacy; it talked about adequacy of everything. One of the things Alabama paid attention to was placing phones that were convenient for people. That affects everyone. For me it was getting involved in staffing studies.
One of the things Judge Johnson did is to come up with minimum staffing standards. But, it is based on really arbitrary thoughts of the people who developed them. In truth if you look at them now you say, ‘My God how could he have set that as a standard because how could that be [adequate] care? It was so low compared to what we think of now. And the implementation is probably 25 years. The state of MD only came up with staffing standards in 1986.”
It changed patients’ treatment and lives.
“The court decision was wonderful. It was back in the heyday of this country when we were paying attention to civil rights. If you look closely at the evolution of the case it didn’t start off as a civil rights case. It was started off to protect the jobs of 99 staff. One could say that maybe it was even very selfish and self-serving, but they used minimum treatment as a vehicle for that. When the lawyers from Alabama really got into it, they went to Washington, D.C. and sought the help of Civil Rights attorneys. So it took on many, many issues. Certainly, someone’s constitutional right to treatment is landmark, but they spelled it out with an individualized treatment plan. There were just so many things that came out of this case. And yet if you look at the specific history of Wyatt-Stickney it was not over and may still not be over as far as I know. I know there were still ongoing cases in ’86 and ’95. So it continues.
What about Wyatt-Stickney and the connection to the de-institutionalization movement?
“That was the concept of right to treatment in the least restrictive setting. Was Wyatt-Stickney responsible for all of it? No. Some of that was opening up community mental health centers. One could also say that the psychotropics, which everyone said were going to cure or change the focus of treatment, played a role. If you had good staffing standards then maybe that could have led to planning and discharge. It’s a landmark case at many levels, but there were other things going on at the time. Medicare opened up and states took advantage of it to utilize nursing homes, as did Maryland. But Wyatt-Stickney certainly sped the process along by having the power of a federal judge and having professional organizations tie into it.”
With the focus today on downsizing of hospitals and community placement for the mentally ill, the question of funding to support and help maintain patients in the community looms large.
“It is complicated in Maryland to talk about where things are [funding decisions] because there are politics behind some of the decisions. There has been tension in the system for fifteen or twenty years that we should close the state hospitals. The truth is it costs a lot. Not for the care of the patients, but to support the grounds and facilities. That would be a saving if those patients were in a different area, yet the legislators in the communities do not want to lose the jobs. We do not have enough resources.
Right now the state is being threatened with about a 42 million dollar shortfall in the Medicaid pot of money for mental health. I think it is a political game. It is my hope that the governor will submit a supplemental budget that will carry us through. There are about 72,000 Marylanders who are in the public mental health system.
If you look at the history of mental health in the state of MD and you go back to the mid 1950’s and everything that I said about Bryce State Hospital you could have said about the state of Maryland. There was a whole set of newspaper articles called ‘Maryland’s Shame.’ (Baltimore Sun, January 9, 1949). It was demonstrating deplorable conditions in the state hospitals; patients uncared for, few professions, all the same things. Wyatt-Stickney could have been whoever was the commissioner in mental health in Maryland.”
And where does social work and standards for social work staff fit in all of this?
“I think that the history of social work is that we have been the advocates of social justice and we have done that well in many areas. But as we have gone into the 90’s and now into 2000s, I sometimes wonder if we have not passed the mantle on to a series of attorneys who can get more bang out of a civil rights class action suit than we can picketing, and marching, and pleading. Maybe at best today it is a combination.
Social workers played a major role in Wyatt-Stickney, not as advocates, but when they developed the staffing standards, social workers provided most of the services. I think social workers even signed seclusion orders because they just didn’t have enough other staff. If you do not have a lot of mental health professionals, often that creates opportunity for the ones you have. And social workers were available. Social workers were one of the four groups that Judge Johnson talked about when he set up staffing ratios…
There was an attempt to look at what patient need was. Then it was based on getting together a group of social workers to determine that. It was a committee of social workers saying, ‘This is what it takes for social work services that are needed for a patient on an acute unit. You need an opportunity to work with the family to do a psychosocial assessment.’ Then you say, ‘Who is going to provide it and then how many hours?’ The truth is I may think this [The Maryland Staffing Project] is a wonderful study, but have there ever been studies comparing a unit that was staffed with this model versus a unit that was staffed in the old model? Have we ever done that? The answer is no. I’ve never seen it done anywhere. I think Judge Johnson moved us along faster than it would have occurred on its own.
In the state of Maryland we came up with staffing standards and presented them with a lot fan fare. We thought, ‘Isn’t this wonderful!’ Then when it was first presented, the state said that they couldn’t afford to implement it. So we implemented about 80% of it. I think that was an improvement.”
Overall are patients in medical systems in this state better off or worse off than they were?
“Oh, they are much better off then they were. We know more than we did then. It is astounding the ignorance that we had in the state-of-the-art in what we say about the way we treated people. If you go back to the early 1920’s and talk about hydrotherapy -where we bombarded people with water – thinking that was the cure. There is still a lot we don’t know. Do we know enough about the brain? No. We are just scratching the surface. And how do we know that what we are doing now is not creating problems along the way that we will find out about later? We are just finding out about genetics. We are trying to provide more services in the community than we have; it just is not enough.”
And the future of mental health…
“There is much more to be done. How do you factor in the new medications that would decrease the need for length of stays? Would that decrease the need for certain kinds of services? Nothing should remain the same. You should really do updates on staffing standards almost yearly. Someone could say today, and I think rightly so, that the patients who are in the hospital today compared to 1985 when we collected data, are sicker. I think it is harder to get patients in hospitals today than it was even 15 years ago.
We are going to continue to struggle. We are going to continue to recognize more need than we have resources for. Hopefully, we will continue to have more advocates. I do hope that the biopsychosocial model is still the focus. We need to put our resources into all three areas, not just one. We improve all three, the biological, psychological and sociological, because all three have room to grow.”
Dr. Weinstein was interviewed by Ms. Sally Crown