State Hospitals are Still Snakepits of Patient Abuse, Betrayal of the Public

Numerous state psychiatric hospitals have recently been exposed for violations and/or deficiencies in patient care and safety, including several that have come under U.S. Department of Justice (DOJ) investigation. The reports show that these facilities are not safe, sanitary or rehabilitative places. The DOJ reports in particular found near-identical violations and deficiencies in each facility it investigated—including inappropriate, excessive or inadequately documented use of seclusion and restraints, as well as drugs being used as chemical restraints.

The number of hospitals and the range of similar abuses throw up a red flag that says “systemic patient civil rights abuses.”

Often referred to as “snakepits” in the early 1900's, for prevalence of violence and degradation and absence of rehabilitation, today's state mental institutions don't appear to have changed much.

The reports:

  • Investigators from the Connecticut state Department of Public Health visited the Connecticut Valley Hospital (CVH, Connecticut's oldest and largest public psychiatric hospital) on September 12, 2007 to look into a patient suicide by hanging—the fourth suicide at the hospital in as many years. While the suicide is tragic enough, the investigators found additional problems at the facility and cited it on behalf of the Centers For Medicare and Medicaid Services, which provides millions of dollars of funding annually to CVH. Among the problems found was that patients are often restrained as “first resort” and as a staff convenience.1

  • In August 2007, a Delaware state investigative committee held a four-hour hearing into abuses at the Delaware Psychiatric Center (DPC). Mothers, fathers, sisters and brothers addressed the committee in excruciating detail about the physical and sexual abuse of their loved ones—patients of the DPC. A former DPC attendant was arrested following a police investigation into a patient whose jaw was broken in three places, on both sides of his mouth. DPC officials at first claimed the patient tripped and hit his chin on a bed frame. In August, state troopers also arrested another former attendant accused of raping a patient.2

  • A May 2007 study of conditions at the Georgia Regional Hospital in Atlanta, commissioned by the Georgia Department of Human Resources, uncovered numerous violations, including physical restraints of patients for no documented reason. The Department of Human Resources' report follows an investigation by The Atlanta Journal-Constitution that reported at least 115 patients at Georgia's state hospital had died under suspicious circumstances between 2002 and 2006. The newspaper also found 194 confirmed cases of physical or sexual abuse. In the state hospital in Savannah, surveyors found, among other things, failure to document the reasons for the use of restraint or seclusion and the use of movies screenings and bingo counted as patient therapy sessions (indicative of fraud).3

  • A May 2006 report by the U.S. DOJ on California's Patton State Hospital found that its psychiatry and psychology services “substantially depart from generally accepted professional standards of care and expose patients to…risk of harm and actual harm.” The report runs down a litany of the facility's failures, including failure to properly diagnose; routine prescribing of inappropriate or unsafe medications without clinical justification; use of restraints and seclusion as a first course of action and the “strikingly high” use of PRN (pro re nata, “as needed”) medication as a form of chemical restraint. Further, it found the hospital failed to foster a safe environment for patients, citing 500 patient-on-patient acts of violence in the preceding six months and a recent trend of suicide and attempted suicide by hanging.4

  • Another May 2006 DOJ report on St. Elizabeth's Hospital in Washington, DC found that the facility “fails to provide its patients with a reasonably safe living environment…patients are subjected to assaults and harm from elopements and suicides…are subjected to undue seclusion and restraints.” One particularly egregious finding was that the hospital's forensic unit restrained or secluded patients for 1,387 hours on weekends compared to 63.62 hours during the week, which “indicates and over-reliance on…seclusion and restraints to compensate for shortage of staff…on weekends.” The DOJ's 66-page report details deficiencies and violations and failures to meet the standard of care across all areas investigated.5

  • The DOJ's July 5, 2005 report on Vermont State Hospital not surprisingly found, among other things, that the institution “consistently uses seclusion and restraint as an intervention of first resort”; “often uses seclusion and restraint for the convenience of staff and/or as initial punishment” and that “Over 90% of restraint incidents at Vermont State Hospital involve strapping patients down to a bed in five-point restraints in a seclusion room - the most restrictive and dangerous form of intervention.” Similar to the aforementioned facilities, the DOJ found deficiencies, violations and departures from standard practice in all areas investigated.6

  • In March 2004, the U.S. DOJ released the findings of their investigation of all four North Carolina state hospitals, which include inappropriate use of restraints and seclusion and failure to ensure reasonable safety of patients. It cites several instances of patients being on combinations or high doses of psychotropic drugs in the absence of any justification in their records. It also reported that nearly half of all North Carolina state hospital patients have a regular or PRN order for benzodiazepines (tranquilizers) but no justification for such use in patients' records. “This practice constitutes chemical restraint, which is in violation of federal regulations…and does not conform to generally accepted professional standards,” the report states. It also reported that two of the hospitals forcefully administer drugs intramuscularly (via syringe) when patients refuse oral medication—a violation of patients' federal constitutional rights—and that in some cases, the forced intramuscular drug is different than the one they refused to take.7

Sadly, these abuses are merely the tail end of psychiatry's long history of patient abuse and failure. A large book could easily be written on the continual state hospital abuses committed, investigated, prosecuted and documented. Here are just a few from the last 60 years to show that, psychiatrically speaking, times have not changed:

  • In the early part of last century, both public and government concern over deteriorating conditions inside U.S. mental institutions caused the American Medical Association to act. In 1931, the AMA hired a physician named John Grimes to conduct an investigation. He came back with an unexpectedly disturbing portrait of overcrowding and woefully inadequate patient diet. Facility attendants were found to conduct themselves like prison guards rather than facilitators of rehabilitation. Dr. Grimes concluded that the primary purpose of state hospitals was not medical but "legal."8

  • In 1944, an Ohio grand jury investigating conditions at Cleveland State Hospital, where several patients had died after being beaten with belts, key rings, and metal-plated shoes, summed up the state of affairs: "The atmosphere reeks with the false notion that the mentally ill are criminals and subhumans who should be denied all human rights…"9

  • In May 1969, then-Illinois State Attorney Edward Hanrahan issued a report at the request of then-Governor Richard Ogilvie, on conditions at the Chicago State Hospital and the Tinley Park Mental Health Facility that found that “All varieties of crime were discovered at both institutions…. Patients were assaulted, murdered and raped by fellow inmates and employees.”10

  • In April 1987, Pennsylvania State Public Welfare Secretary John F. White, Jr. formed a special task force to investigate Byberry State Hospital, a now-closed state institution with one of the most horrifying records of patient death and abuse. In September of that year, the group issued their report in which it said that patients were being neglected, beaten and sexually abused. The report called for “immediate and drastic action to reverse the history of neglect, poor management, absence of treatment and rampant abuse.”11

It is tempting to blame “the system” in situations like these. Certainly the psychiatric system—as evidenced by nothing more than what has been exposed in America's public psychiatric institutions—routinely and utterly fails its patients and the public but it is individuals that commit abuses. Individuals condone environments where abuse is the norm. Such individuals can and should be identified; their crimes against patients documented and criminal charges brought.

Such abuse also prompts the question “What is the state paying for?” According to DOJ's findings and other reports, it appears that, broadly speaking, government and the public are being defrauded because these reports show that these facilities are generally failing to meet the standard of care. They are paid to provide such a standard and, in providing less or providing harmful “care,” they commit fraud in general. The state hospital purpose appears to be one of keeping people institutionalized at the state's expense with no concept or intention of improvement or rehabilitation. One could conclude that the system exists in this condition not for the benefit of patients but for the purpose of keeping psychiatrists and mental health staff employed—paid with tax dollars.

Judging from foregoing reports, the state hospital appears to be a most fruitful source of criminal prosecution for patient abuse and fraud and should be high on any Medicaid administrator, fraud investigator, personal injury/civil rights attorney and law enforcement's list.

The Citizens Commission on Human Rights (CCHR) was established in 1969 by the Church of Scientology to investigate and expose psychiatric violations of human rights. The CCHR documentary, “Psychiatry: An Industry of Death,” exposes the origin of abuses in the early mental asylums and to the state hospitals right up to the present. You can purchase a copy at


Steve Wagner
Director of Litigation & Prosecution
Citizens Commission on Human Rights

1 “Another investigation finds big problems at psychiatric hospital,” Associated Press, 19 Sept. 2007.

2 “Families tell of beatings, assaults,” The News Journal, 22 Aug. 2007.

3 “Report blisters mental hospital…”, Atlanta Journal-Constitution, 9 May 2007

4 “Re: Patton State Hospital, Patton, California,” Report to California Governor Schwarzenegger by the U.S. Department of Justice Civil Rights Division, 2 May 2006.

5 “Re: CRIPA Investigation of St. Elizabeth's Hospital, Washington, D.C.,” Report to Washington, D.C. Mayor Williams by the U.S. Department of Justice Civil Rights Division, 23 May 2006.

6 “Re: CRIPA Investigation of the Vermont State Hospital, Waterbury, Vermont,” Report to Vermont Governor Douglas by U.S. Department of Justice Civil Rights Division, 5 July 2005.

7 “Re: North Carolina's Public Mental Health Hospitals, Dorothea Dix…,” Report to North Carolina Governor Easley by the U.S. Department of Justice Civil Rights Division, 17 Mar. 2004.

8 John Maurice Grimes, Institutional Care of Mental Patients in the United States (self-published, 1934), xiv, pp. 15-43, 95-99 and Albert Deutsch, The Shame of the States (Harcourt, Brace, 1948), pp.57-58 (as cited in Robert Whittaker, Mad in America [Perseus Publishing, Cambridge, MA, Dec. 2001], p. 70.)

9 Ibid. p. 71.

10 “Murder, vice in hospital, report says,” Daily Telegraph, 29 May 1969

11 William Ecenbarger, “The shame that was Byberry,” The Philadelphia Enquirer,” 10 July 1988.

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