Mental health: revisited through the courtroom
By MICHAEL D. KLEMENS
A Cook County circuit court judge has rebuked the Department of Mental Health and Developmental Disabilities (DMHDD) for the operation of state psychiatric facilities and challenged the department and state lawmakers to correct deficiencies. "We recommend that the General Assembly and DMH&DD take necessary actions to correct the urgent problems that exist in DMH&DD facilities which deny residents even the constitutionally mandated minimally adequate care, services, habilitation and treatment in a humane environment standard . . . without being subjected to the incidents of atrocious abuses that have been occurring," Judge Marjan Staniec wrote in a March 6 opinion.
The issue before Staniec was whether or not DMHDD was complying with the terms of a 15-year-old consent decree for a narrow class of clients, those both mentally retarded and mentally ill who live in state institutions. The 1975 decree in the class action suit of Nathan v Levitt required certain levels of treatment for the approximately 300 dually diagnosed individuals who are in state facilities at any given time. In 1986 Staniec named Protection and Advocacy Inc. (P&A) as the court's independent monitor and ordered the private agency to undertake a series of studies for the court.
P&A reviewed records at state facilities between April and October 1987 and concluded that injuries to Nathan class clients were common and underreported, as were incidents of physical and sexual abuse. For the six-month period of its study P&A reviewed files on 83 class members and found 127 reported injuries. Elsewhere in the files the monitor found another 30 injuries that had gone unreported. The monitor questioned both the level of injuries, at an average of 1.9 per class member, and the 20 percent underreporting rate. The monitor also found that 26 of the 83 sampled clients (or 31 percent) were physically or sexually abused during the period of the study. Underreporting of abuse was put at 90 percent by the monitor. Finally, P&A suggested that clients were being put in restraints or in seclusion as punishment and not for therapeutic purposes.
A second part of the P&A study looked at the effectiveness of treatment. P&A brought in an expert in the field of dually diagnosed patients, William I. Gardner, a University of Wisconsin psychologist. He evaluated the treatment being given class members, spending one day each at Elgin Mental Health Center, at Chicago-Read Mental Health Center and at the Howe Developmental Center.
Gardner found the staff to be motivated and committed but lacking the skills needed to handle the difficult population. He found programs to teach habilitation (self-care and daily living skills) adequate, but the programs providing psychological treatment were inadequate. Gardner recommended better training for the staff and increased use of professionals.
Gardner also testified that in Wisconsin relatively few dually diagnosed patients live in state mental facilities. He reasoned that, with services in the community, many of the individuals now in Illinois institutions could function in less restrictive environments.
Other treatment weaknesses identified by Gardner:
• Drug treatment was overused and misused. It was often the major or only treatment for patients, even those who did not have problems that could be treated with drugs.
• Psychological treatment plans were not drawn to address the symptoms that resulted in the individual's hospitalization.
• Psychological treatment was done in groups not individually.
• Reliance was upon punishment in group token and penalty programs, by which individuals get a reward at the end of each day for positive behavior and lose something for negative actions.
• Lack of a system to monitor patient behavior made it impossible to know whether treatment was working.
• Too little interaction occurred between doctors and psychologists.
Zena Naiditch, executive director of P&A, believes that her agency's findings offer a "snapshot" of what it is like generally in the state institutions. The department, however, maintains that the information is dated and that it has made progress since. Penny Strong, DMHDD spokesperson, says that since the 1988 reports upon which Staniec's ruling is based, the department has strengthened training in abuse and neglect, has put in place its internal office of inspector general and added new staff to allow better treatment.
Judge Staniec sided with Protection and Advocacy and ruled that DMHDD had failed to comply with the consent order. He ordered P&A to continue as the court's monitor. He wrote that he wanted not to intrude upon legislative prerogative but to focus attention on the findings of his court. He made several suggestions for improvement, including:
• Stronger central office coordination between, supervision of, and control over facilities to attain uniformity in the way that facilities are operated.
• Improved management and supervisory skills and better staff training.
• Establishment of an independent ombudsman, on the order of the federal government General Accounting Office, to monitor and evaluate the facilities and report periodically to DMHDD and the General Assembly.
• Psychological screening of new direct-care staff candidates to identify those without the emotional stability to handle the stress.
• Disciplinary sanctions for personnel who violate policy or who abuse patients.
• Allowing in abuse cases for the prevailing party to recover attorney fees and costs.
• Keeping statistics of actions on abuse and neglect cases taken by various agencies, such as DMHDD and State Police.
Staniec and P&A have given lawmakers issues to think about this spring. Abuse and neglect outrage everyone. Less incendiary but nearly as important are the questions that Gardner raises about the treatment offered in state facilities.
May 1990/Illinois Issues/25