Incarcerated Mental Patients Gain Right to Treatment

A federal judge declared that mental patients incarcerated against their will without criminal proceedings had a right to adequate therapy. The case created minimum standards for the care of people with mental retardation and mental illness.

Summary of Event

Progress in psychology and psychiatry in the twentieth century made many mental institutions appear backward. Many American states used their asylums as pens into which the aged, the retarded, and the ill were herded to keep them away from the rest of society. Institutions often lacked finances to provide inmates with adequate treatment. For therapists, the issue was ethical and medical: Improved techniques could not help patients who were not treated, while confinement without treatment could make patients worse. For lawyers, the issue was constitutional and procedural: Patients were committed against their wishes by civil proceedings that lacked the protections constitutionally guaranteed to defendants in criminal trials. For mental patients, the issue was sanity and survival: Forced hospitalization without much hope of recovery or rehabilitation sentenced many of them to a living death. Mental illness;patients’ rights[patients rights]
[kw]Incarcerated Mental Patients Gain Right to Treatment (Mar. 12, 1971)
[kw]Mental Patients Gain Right to Treatment, Incarcerated (Mar. 12, 1971)
[kw]Patients Gain Right to Treatment, Incarcerated Mental (Mar. 12, 1971)
[kw]Right to Treatment, Incarcerated Mental Patients Gain (Mar. 12, 1971)
[kw]Treatment, Incarcerated Mental Patients Gain Right to (Mar. 12, 1971)
Mental illness;patients’ rights[patients rights]
[g]North America;Mar. 12, 1971: Incarcerated Mental Patients Gain Right to Treatment[00230]
[g]United States;Mar. 12, 1971: Incarcerated Mental Patients Gain Right to Treatment[00230]
[c]Civil rights and liberties;Mar. 12, 1971: Incarcerated Mental Patients Gain Right to Treatment[00230]
[c]Laws, acts, and legal history;Mar. 12, 1971: Incarcerated Mental Patients Gain Right to Treatment[00230]
[c]Health and medicine;Mar. 12, 1971: Incarcerated Mental Patients Gain Right to Treatment[00230]
Johnson, Frank M., Jr.
Birnbaum, Morton
Bazelon, David L.

For many therapists and lawyers, the resolution of ethical, medical, and constitutional issues was a “right to treatment.” Existing law mandated states merely to avoid harming inmates and to provide reasonable custodial conditions. A right to treatment required that a state provide adequate treatment when it committed persons to mental hospitals. The right of every individual to life and liberty made it insufficient for the state merely to care; it demanded that the state make at least a minimal attempt to cure.

Morton Birnbaum, a lawyer and medical doctor, wrote the seminal defense of a constitutional, legal, and moral right to treatment in 1960. Birnbaum noted that many mental patients could be helped if mental facilities and staffs were professionalized and funded. Many states, however, ignored mental hospitals, in part because patients did not vote or otherwise threaten or concern officials. Birnbaum argued that the due process clause of the Fourteenth Amendment Fourteenth Amendment (U.S. Constitution) (“nor shall any State deprive any person of life, liberty, or property, without due process of law”) prohibited states from confining persons to institutions without treatment because treatment was the only excuse for depriving them of liberty. Reports from the American Medical Association, the American Bar Association, the American Psychiatric Association, and the Subcommittee on Constitutional Rights of the Senate Judiciary Committee reinforced Birnbaum’s description of the inadequacies of psychiatric confinement across the United States.

Increased attention to such conditions inspired laws in many U.S. states and in the District of Columbia. The statute for the nation’s capital was held to mandate a right to treatment by the Court of Appeals for the District of Columbia in Rouse v. Cameron (1966). Rouse v. Cameron (1966) Judge David L. Bazelon’s opinion in that case suggested that the Constitution might authorize a right to treatment even if the statute had not. The conditions that drove legislatures and courts to formulate a right to treatment were characterized by the Bryce State Mental Hospital Bryce State Mental Hospital in Tuscaloosa, Alabama. Alabama spent less than any other state on mental patients, so Bryce was poorly funded. Lack of funds and overcrowding contributed to the inadequacy of facilities. Most patients had no privacy in lavatories or dormitories. Patients were offered poor clothing, inadequate and unsanitary nutrition (Bryce budgeted fifty cents per patient per day for food), and few productive outlets or activities. Some patients had no beds. Many patients were constantly drugged. Many went days without bathing, in some cases because dozens had to share a single shower. On one surprise visit, reporters found walls and toilets covered with excrement and floors soaked with urine.

Budget cuts at Bryce in 1970 rendered an inadequate staff skeletal. Those who dealt directly with patients included only one clinical psychologist with a doctoral degree, three medical doctors with some psychiatric training, two social workers, and no board-certified psychiatrist. Other staff were overworked and underqualified. Nurse’s aides, for example, were not required to have graduated from high school. Most nonprofessionals were minimally supervised. Many of the staff exhibited indifference or brutality toward their charges, some of whom suffered deaths that were arguably preventable. These conditions made it unclear whether Bryce was meeting even the traditional legal standard of reasonable care. Inadequate funds, facilities, and staffing made individualized treatment of patients impossible. Of the hospital’s more than five thousand residents, almost half were aged or retarded patients who neither required nor received any psychiatric care. Most patients, convicted of no crimes but committed to Bryce and not free to leave, received little treatment. At best, Bryce Hospital maintained its residents without helping them. At worst, it maimed them through neglect and indifference.

Bryce employees laid off because of budget cuts and citizens concerned about the rights of mental patients protested the budget cuts and demanded a higher standard of care. Largely on their own, they formulated a constitutional right to treatment similar to the views propounded by Birnbaum and Bazelon. On October 23, 1970, they filed suit in federal court in the name of several patients at Bryce and their legal guardians. Heading the list of plaintiffs was Ricky Wyatt, a patient at the hospital. The leading defendant was Dr. Stonewall B. Stickney, Stickney, Stonewall B. the mental health officer for Alabama. Chief Judge Frank M. Johnson, Jr., of the U.S. District Court for the Middle District of Alabama heard Wyatt v. Stickney on January 4, 1971, and issued his first decision (there was no jury) on March 12.

Judge Johnson found that, even before budget cuts, Bryce failed to meet minimal medical or custodial standards for treatment. Since most patients were not getting treatment, he reasoned, they were in effect imprisoned at Bryce. He found this especially true for the geriatric, mentally retarded, and other nonpsychotic inmates who should not have been forced into the asylum. For the truly mentally ill, Judge Johnson followed the logic that Birnbaum had articulated a decade earlier. “Due process” required trial and conviction before imprisonment, but most patients at Bryce had been involuntarily committed without criminal proceedings. Judge Johnson concluded in a brief, candid, and remarkably dispassionate opinion that because the only constitutionally acceptable reason for depriving noncriminal patients of their liberties was therapy or cure, patients had a constitutional right to treatment.

Alabama insisted that it lacked the money necessary to make treatment available to the inmates, but Judge Johnson replied that constitutional rights could not be sacrificed to economics. Alabama would have to find the money to treat people whom it sent to its hospitals because, Judge Johnson argued, “There can be no legal (or moral) justification for the State of Alabama’s failing to afford . . . adequate treatment . . . to the several thousand patients who have been civilly committed.”

Ten years of ethical, medical, and legal arguments had found their way into constitutional law. In a second decision announced on December 10, 1971, Judge Johnson defined the right to treatment more extensively. The Constitution demanded that each state provide a humane environment, a sufficient complement of qualified staff, and treatment planned around the needs of individual inmates. Judge Johnson detailed how Bryce and other mental hospitals in Alabama had defaulted on each criterion. In subsequent decisions for more than a decade, Judge Johnson would wrestle with the difficulties of achieving state compliance with his decrees, but a constitutional right to treatment had been declared. If the state deprives individuals of freedom “for their own good,” it must make at least a minimal effort to secure the individuals that good.


Wyatt v. Stickney led to a decade of litigation, appeals, and maneuvers within federal courts and resulted in Alabama’s mental health system being run by a federal appointee. The most direct impact of the right to treatment was to make critical scrutiny of Alabama’s institutions routine. During the extended litigation, all three Alabama mental institutions were included in the cases. Having defined the right to treatment as a constitutional requirement for individualized treatment by qualified staff in a humane environment, Judge Johnson required institutions to justify their practices by each criterion in that definition. Judge Johnson also set up “human rights committees” to monitor implementation of reforms and expose any shortcomings in compliance with court orders.

Immediately, then, the Wyatt case inspired Judge Johnson to lead a revolution in treatment of the mentally ill. The demand for individualized treatment compelled institutional staff to diagnose and respond to the problems of patients or to release them. At the very least, the state could “warehouse” the mentally ill only if it prepared an inventory of inmates and their problems. Each patient would receive more attention, and the retarded and the aged who did not belong in a mental institution would be reassigned to more appropriate residences.

Confinement without treatment often makes healthy people sick and sick people sicker, so individualized treatment forced the state to suit treatment regimens to the reasons for confinement. Defendants found not guilty of crimes because of insanity could no longer be imprisoned without hope of release. The court and its agents evaluated the qualifications of staff and ordered the hiring of more and better trained attendants. To augment the amount of attention each patient could anticipate, the maximum population at each institution was reduced, in part through removal of inmates who were not mentally ill. Patients who read and understood the court’s decrees became more conscious of their rights and less docile, forcing staff to be more professional and humane. Recalcitrant staff unwilling to upgrade their care left or were reassigned.

A broader impact of Wyatt was to expose existing conditions and to institute routine means of improving the environment at mental institutions. The human rights committees, the U.S. Department of Justice, and even the Federal Bureau of Investigation were drawn into the Alabama case to contest often extravagant claims of improvement and to force the state to meet its newly defined constitutional responsibilities. The committee for Partlow Mental Hospital, for example, recruited a former patient from Partlow to inform outsiders about true conditions in the hospital. Judge Johnson and his agents and advisers would eventually define, in great detail, minimal standards for treatment. The constant threat of judicial, federal, or citizen intervention gave patients a phalanx of champions and the state a host of critics to please.

The secrecy of mental institutions had been breached. Judge Johnson’s declaration was implemented elsewhere more quickly and to a greater extent than in Alabama. More than a dozen states legislated expanded rights for inmates of mental institutions. Many courts readily accepted Wyatt v. Stickney as precedent. Lawyers and doctors began to work out its implications in professional and political discussions. A less immediate but perhaps more profound impact of this landmark case was to encourage citizens and professionals concerned about mental health to push governments to do more for institutionalized mental patients. Procedural safeguards before and after commitment were expanded and strengthened in many jurisdictions to differentiate asylums from prisons in a substantial manner.

The U.S. Supreme Court implicitly reaffirmed the right to treatment in Jackson v. Indiana (1972) Jackson v. Indiana (1972) when it stated that involuntary commitment must advance some justifiable purpose. This means both that states must articulate and defend their purpose when they deprive individuals of freedom and that the incarceration must advance that purpose. In Youngberg v. Romeo (1982), Youngberg v. Romeo (1982) the court also found that the Eighth Amendment ban on cruel and unusual punishment and the due process clause of the Fourteenth Amendment demanded adequate care and training for the institutionalized retarded. Both decisions clearly imply a right to treatment.

Perhaps the most far-reaching impact of Wyatt v. Stickney was to induce communities to care for many patients outside institutions. The duty to provide individualized treatment inclined many states to remove all but the most seriously ill patients from state institutions. Many aged and retarded citizens began living in communities rather than asylums, which represented a boon to individual liberty. The right to treatment did not in itself force states to upgrade their treatment of the mentally ill. It was, however, an important prod to doctors, lawyers, and other citizens to remember that the infirm are entitled to care and protection. Mental illness;patients’ rights[patients rights]

Further Reading

  • Birnbaum, Morton. “The Right to Treatment.” American Bar Association Journal 46 (May, 1960): 499-505. Presents the seminal argument that set out in legal terms the right of involuntarily institutionalized mental patients to minimal therapy and moved some reformers to try to secure a “right to treatment.”
  • Cooper, Phillip J. Hard Judicial Choices: Federal District Court Judges and State and Local Officials. New York: Oxford University Press, 1988. Chapter 6 provides an overview of conditions in mental institutions and raises the major psychological, mental, penal, and legal issues. Chapter 7 chronicles the lengthy litigation in Wyatt v. Stickney. Readers unfamiliar with legal jargon and judicial process will have some difficulty understanding parts of these chapters, but the coverage makes it worth the trouble.
  • Neier, Aryeh. Only Judgment. Middletown, Conn.: Wesleyan University Press, 1982. Engaging book by a leading activist for human rights features an informative chapter on legal attempts to reform mental institutions. Readers unfamiliar with legal writing will be able to understand and appreciate this analysis of what the legal process can and cannot do about the rights of the involuntarily institutionalized.
  • _______. Taking Liberties: Four Decades in the Struggle for Rights. New York: PublicAffairs, 2003. Memoir focuses on the author’s work as a human rights activist. Chapter 3, “Opening Asylums,” offers discussion relevant to the topic of the right to treatment.
  • Saks, Elyn R. Refusing Care: Forced Treatment and the Rights of the Mentally Ill. Chicago: University of Chicago Press, 2002. Examines when, if ever, a mentally ill person should be treated against his or her will. Includes case studies.
  • “The Wyatt Case: Implementation of a Judicial Decree Ordering Institutional Change.” Yale Law Journal 84 (May, 1975): 1338-1379. Excellent account of how fiscal and political resistance undermined enforcement of the right to treatment. Shows that rights as enunciated by courts are often severely compromised by government agencies that “lost” in court. Somewhat technical.
  • Yarbrough, Tinsley E. Judge Frank Johnson and Human Rights in Alabama. 2d ed. Tuscaloosa: University of Alabama Press, 2002. Accessible and interesting chronicle of the first decades of Judge Johnson’s career provides details about conditions at mental institutions in Alabama and about the political and legal forces arrayed in the battle over the right to treatment.

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