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Braggs v. Dunn

United States District Court, M.D. Alabama, Northern Division

June 27, 2017

EDWARD BRAGGS, et al., Plaintiffs,
v.
JEFFERSON S. DUNN, in his official capacity as Commissioner of the Alabama Department of Corrections, et al., Defendants.

          LIABILITY OPINION AND ORDER AS TO PHASE 2A EIGHTH AMENDMENT CLAIM

          MYRON H. THOMPSON, UNITED STATES DISTRICT JUDGE

         I. INTRODUCTION 3

         II. PROCEDURAL BACKGROUND 5

         III. FACTUAL BACKGROUND 6

         A. ADOC Facilities and Organizational Structure 8

         B. MHM Organizational Structure 12

         C. Summary of Factual Findings 15

         1. Fact Witnesses 15

         2. Expert Witnesses 24

         IV. EIGHTH AMENDMENT LEGAL STANDARD 30

         V. FINDINGS OF FACT AND CONCLUSIONS OF LAW 33

         A. Serious Mental-Health Needs 34

         B. Actual Harm and Substantial Risks of Serious Harm Posed by Inadequate Care 39

         1. Contributing Conditions 46

         a. Overcrowding 47

         b. Mental-Health Understaffing 49

         c. Correctional Understaffing 59

         2. Identification and Classification of Prisoners' Mental-Health Needs 71

         a. Inadequate Intake Process 72

         b. Inadequate Referral Process 79

         c. Inadequate Classification of Mental-Health Needs d. Inadequate Utilization of Mental-Health Units 86

         3. Inadequate Treatment Planning 89

         4. Inadequate Psychotherapy 96

         5. Inadequate Inpatient Care 109

         a. Improper Use of Mental-Health Units 110

         b. Inadequate Out-of-Cell Time and Programming 115

         c. Lack of Hospital-Level Care 128

         6. Inadequate Suicide Prevention and Crisis Care 133

         a. Failure to Provide Crisis Care to Those Who Need It 141

         b. Placement of Prisoners in Crisis in Dangerous and Harmful Settings 153

         c. Inadequate Treatment in Crisis Care 157

         d. Unsafe Crisis Cells 160

         e. Inadequate Monitoring of Suicidal Prisoners 167

         f. Inappropriate Release from Suicide Watch and Inadequate Follow-up 173

         7. Inappropriate Use of Disciplinary Actions 178

         8. Inappropriate Placement and Inadequate Treatment in Segregation 190

         a. Background on Segregation 193

         i. Consensus among Correctional and Mental-Health Professionals on Segregation 193

         ii. ADOC's Segregation Units199

         b. ADOC's Segregation of Mentally Ill. Prisoners 205

         i. ADOC's Segregation-Placement Practices 206

         ii. Treatment and Monitoring in Segregation Units 214

         c. Segregation of Prisoners with Serious Mental Illness 225

         9. Tutwiler 230

         10. Other Issues 236

         C. Deliberate Indifference 242

         1. ADOC's Knowledge of Harm and Risk of Harm 250

         2. ADOC's Disregard of Harm and Risk of Harm 261

         a. ADOC's Failure to Exercise Oversight of the Provision of Mental-Health Care 264

         b. ADOC's Unreasonable Responses to Identified Deficiencies 276

         D. Ongoing Violation 283

         E. Ex parte Young Defenses 291

         VI. CONCLUSION 299

         I. INTRODUCTION

         The plaintiffs in this phase of this class-action lawsuit are a group of seriously mentally ill state prisoners and the Alabama Disabilities Advocacy Program (ADAP), which represents mentally ill prisoners in Alabama. The defendants are the Commissioner of the Alabama Department of Corrections (ADOC), Jefferson Dunn, and the Associate Commissioner of Health Services, Ruth Naglich, who are sued only in their official capacities. The plaintiffs assert that the State of Alabama provides constitutionally inadequate mental-health care in prison facilities and seek injunctive and declaratory relief. They rely on the Eighth Amendment, made applicable to the States by the Fourteenth Amendment and as enforced through 42 U.S.C. § 1983. Jurisdiction is proper under 28 U.S.C. § 1331 (federal question) and § 1343(a)(3) (civil rights).

         After a lengthy trial, this claim is now before the court for resolution on the merits. Upon consideration of the evidence and arguments, the court finds for the plaintiffs in substantial part. Surprisingly, the evidence from both sides (including testimony from Commissioner Dunn and Associate Commissioner Naglich as well as that of all experts) extensively and materially supported the plaintiffs' claim.

         II. PROCEDURAL BACKGROUND

         This extremely complex case has been split into three phases: Phase 1 involved claims under Title II of the Americans with Disabilities Act (ADA), codified at 42 U.S.C. § 12131 et seq., and § 504 of the Rehabilitation Act, codified at 29 U.S.C. § 794, claiming discrimination on the basis of physical disabilities and failure to accommodate those disabilities. The parties settled Phase 1. See Dunn v. Dunn, 318 F.R.D. 652 (M.D. Ala. 2016) (Thompson, J.). Phase 2A involves Eighth Amendment, ADA, Rehabilitation Act, and due-process claims regarding mental-health care. The parties settled the Phase 2A ADA and Rehabilitation Act claim. The due-process claims are pending before the court for settlement approval.[1] Phase 2B will focus on medical-care and dental-care claims under the Eighth Amendment.

         This opinion resolves only the Phase 2A Eighth Amendment claim of inadequate mental-health care.[2] The court has certified a Phase 2A plaintiff class consisting of all persons with a serious mental illness who are, or will be, confined within ADOC's facilities, excluding Tutwiler Prison for Women and the work-release centers. See Braggs v. Dunn, 317 F.R.D. 634 (M.D. Ala. 2016) (Thompson, J.). While mentally ill prisoners at Tutwiler are not part of the class, ADAP, as Alabama's designated protection and advocacy organization for the mentally ill, brought claims on their behalf. A seven-week trial followed.

         III. FACTUAL BACKGROUND

         Mental-health care in this opinion refers to screening, treatment, and monitoring of mental illnesses, as well as ADOC's policies and practices regarding mentally ill prisoners, including decisions on disciplinary sanctions and housing placements.[3] Before diving in to the details of weeks' worth of testimony and thousands of pages of documentary evidence regarding mental-health care within ADOC, the court pauses to provide some background information on ADOC and its mental-health contractor, as well as a summary of the factual findings.

         A. ADOC Facilities and Organizational Structure ADOC runs 15 major facilities (14 for men and the Tutwiler Prison for Women) and houses around 19, 500 prisoners in its major facilities.[4] Approximately 3, 400 prisoners are on the mental-health caseload, meaning that they receive some type of mental-health treatment, such as counseling or psychotropic medications.

         MAJOR ADOC FACILITIES[5]

Facility

Location

Population

Bibb

Brent

1847

Bullock

Union Springs

1522

Donaldson

Bessemer

1474

Draper

Elmore

1144

Easterling

Clio

1457

Elmore

Elmore

1186

Fountain

Atmore

1242

Hamilton

Hamilton

275

Holman

Atmore

941

Kilby

Mt. Meigs

1126

Limestone

Harvest

2214

St. Clair

Springville

975

Staton

Elmore

1382

Ventress

Clayton

1254

Tutwiler

Wetumpka

880

         Three of the major facilities, Bullock, Donaldson, and Tutwiler, serve as ‘treatment hubs' for mental-health services, containing a residential treatment unit (RTU) and/or a stabilization unit (SU). These two types of units, together referred to as ‘mental-health units' or ‘inpatient-care units, ' house and treat the most severely mentally ill prisoners. The rest of those on the mental-health caseload receive their care through outpatient services: they live in a unit that is not focused on treatment and ordinarily must go to a different part of the prison to see a mental-health provider.

         Under the administrative regulations governing ADOC's mental-health care, RTUs are for mental-health patients who suffer from “moderate impairment in mental health functioning” that puts them at risk in a general-population setting. Joint Ex. 107, Admin. Reg. § 613-2 (doc. no. 1038-130). RTUs are intended to provide a therapeutic environment to mentally ill patients and to help them develop coping skills necessary for placement in general population. RTUs can be ‘closed, ' meaning that each patient lives in an individual cell with little time spent outside the cell; ‘semi-closed, ' meaning that the patient still stays in an individual cell but is let out of the cell more often; or ‘open, ' meaning that the patient lives in an open dormitory with other RTU patients.

         SUs are for patients who are suffering from acute mental-health problems--such as acute psychosis or other conditions causing an acute risk of self-harm--and have not been stabilized through other interventions. SUs are intended to stabilize the patient as quickly as possible so that the patient can return to a less restrictive environment. All SU patients are housed in individual cells.

         Altogether, the two male treatment hubs have 346 RTU beds and 30 SU beds: Bullock has 250 RTU beds and a 30-bed SU for male prisoners, and Donaldson has an additional 96-bed RTU. Tutwiler has 30 RTU beds and eight SU beds for women. These units provide services to about 2 % of ADOC's overall population.

         ADOC is headed by Commissioner Dunn. Associate Commissioner for Health Services Naglich heads the Office of Health Services (OHS), which is responsible for overseeing the provision of medical and mental-health care to prisoners. ADOC uses private contractors to deliver medical and mental-health care services to prisoners. Under the mental-health contract with a third-party vendor, OHS has access to the contractor's internal documents and records, and the contractor is required to send certain reports, such as monthly operating reports and annual contract-compliance reports, to OHS. The only OHS staff member with mental-health expertise is Dr. David Tytell, the chief clinical psychologist. Dr. Tytell serves as the main liaison between the mental-health contractor and ADOC, and communicates with the contractor's program director at least weekly. ADOC also directly employs ‘psychological associates, ' who are counselors responsible for conducting certain psychological tests at intake and for providing group sessions and classes for non-mentally ill prisoners. They report to their respective facilities' wardens, rather than OHS or the mental-health contractor.

         B. MHM Organizational Structure

         MHM Correctional Services, Inc. is ADOC's contractor for mental-health care. MHM is a for-profit corporation that provides medical and mental-health services to correctional facilities across the country.

         MHM's regional office in Alabama is headed by its program director Teresa Houser. She serves as the main liaison between ADOC and MHM. Dr. Robert Hunter, a psychiatrist who serves as the medical director for the Alabama regional office, is charged with supervising psychiatrists and certified registered nurse practitioners (CRNP) stationed at various ADOC facilities. Both Houser and Hunter communicate frequently with ADOC officials, including Associate Commissioner Naglich and Dr. Tytell.

         MHM employs a variety of administrative and clinical personnel to fulfill its contract with ADOC. In its regional office, Houser supervises various administrators and managers, such as the continuous quality improvement (CQI) manager, who conducts informal audits of MHM's performance, and the chief psychologist, who supervises psychologists and conducts training for MHM employees. At the facility level, MHM employs site administrators to provide administrative oversight; these administrators are counselors by training. MHM also employs approximately 45 full-time ‘mental-health professionals' (MHPs), who are masters-level mental-health counselors, at prisons across the State. As of December 2016, MHM employed four psychiatrists and eight CRNPs in Alabama; these providers are qualified to diagnose mental illnesses, prescribe psychotropic medication, and provide psychotherapy across multiple facilities. MHM also employs three psychologists and three registered nurses (RNs) for the entire State. The RNs are stationed at the three treatment hubs, Bullock, Donaldson, and Tutwiler; they administer medication, provide crisis intervention, and supervise the licensed practical nurses (LPNs) at their facilities. MHM employs approximately 40 LPNs, individuals with 12 to 15 months of health-care training. The LPNs are responsible for conducting mental-health intake at Kilby and Tutwiler, monitoring medication compliance, maintaining medication records, and conducting side-effects monitoring tests for psychotropic medications. While the LPNs stationed in the mental-health treatment units are supervised by the on-site RN, at all other places, including at intake screening, LPNs have no on-site supervision. Lastly, MHM employs six to eight activity technicians, who organize or assist in therapeutic, social, and recreational activities for patients in mental-health units.

         C. Summary of Factual Findings

         1. Fact Witnesses

         Over the course of seven weeks, the court heard testimony as to whether ADOC's mental-health care violates mentally ill prisoners' constitutional rights. The trial opened with the testimony of prisoner Jamie Wallace, who suffered from severe mental illnesses, intellectual disability, and substantial physical disabilities. Wallace stated that he had tried to kill himself many times, showed the court the scars on arms where he made repeated attempts, and complained that he had not received sufficient treatment for his illness. Because of his mental illness, he became so agitated during his testimony that the court had to recess and reconvene to hear his testimony in the quiet of the chambers library and then coax him into completing his testimony as if he were a fearful child. The court was extremely concerned, by what it had seen and heard from this plaintiff, about the fragility of his mental health. At the end of Wallace's testimony and out of his presence, the court informed the attorneys for both sides that it wanted a full report on his mental condition and the steps that were being taken to address that condition. Unfortunately, and most tragically, ten days after Wallace testified, he killed himself by hanging. Because it appeared that adequate measures may not have been put in place to prevent Wallace's suicide, the court put the parties into mediation to attempt to come up with immediate, interim procedures to prevent future prisoner suicides. The parties eventually came up with such procedures. Without question, Wallace's testimony and the tragic event that followed darkly draped all the subsequent testimony like a pall.

         The plaintiffs' case then proceeded with testimony from Commissioner Dunn, who aptly described the prison system as wrestling with a “two-headed monster”: overcrowding and understaffing. Dunn Testimony at 26. The court also heard from Associate Commissioner Naglich and MHM's program director Houser, for whom overcrowding and understaffing (both as to correctional staff, as noted by Dunn, and mental-health staff) were a mantra. They, with admirable candor, as with many other fact witnesses and the experts from both sides, essentially agreed that the staffing shortages, combined with persistent and significant overcrowding, contribute to serious systemic deficiencies in the delivery of mental-health care.

         The inadequacies in the mental-health care system start at the door, with intake screening for prisoners who need mental-health care. ADOC boasts one of the lowest mental-illness prevalence rates among correctional systems in the country. But this is not because Alabama has fewer mentally ill prisoners than the rest of the country or the best mental-health care system for its prisoners; rather, according to experts from both sides, this is because a substantial number--likely thousands--of prisoners with mental illness are missed at intake and referrals for evaluation and treatment are neglected. As a result, many ADOC prisoners who need mental-health care go untreated.

         Even when identified, mentally ill prisoners receive significantly inadequate care. Mental-health and correctional staffing shortages drive inadequate treatment. Individual and group counseling sessions are delayed or canceled due to shortages of counselors and correctional officers to escort prisoners to the sessions and to provide security. As a result, mental-health staff often have to resort to cell-side contacts, which cannot be considered substitutes for meaningful, confidential, out-of-cell appointments. Treatment planning is often pro forma and not individualized and fails to provide a meaningful and consistent course of treatment. Mental-health units intended as a therapeutic environment for the most severely ill prisoners operate like segregation units, with little counseling, therapeutic programming, or out-of-cell time. ADOC does not provide hospital-level care for those who need it.

         ADOC also fails to provide adequate care to prisoners expressing suicidality and undergoing mental-health crises. Mental-health staff fail to use appropriate risk-assessment tools to determine suicide risk. ADOC has an insufficient number of crisis, or ‘suicide-watch, ' cells--special cells for the protection of suicidal prisoners. Because they have a limited number of cells to work with, they gamble on which prisoners to put in them and frequently discount prisoners' threats of self-harm and suicide. The insufficient number of crisis cells also results in the use of unsafe rooms such as shift offices to house suicidal prisoners. The suicide-watch cells that do exist are dangerous: visibility into many of the cells is poor, making it difficult to monitor; many cells have tie-off points for ligatures that can be used for suicide attempts; dangerous items used for inflicting self-injury are often found. Prisoners in these cells receive less contact with and less monitoring by providers than the acuity of their condition demands. When they are released to general population or segregation, prisoners receive inadequate follow-up.

         ADOC's segregation practices inflict further harm on prisoners suffering from inadequate mental-health care. Due to the effects of isolation, placement in segregation endangers mentally ill prisoners, and the risk of harm increases with the length of isolation and the severity of their mental illness. This danger is compounded by the limited access to mental-health care and monitoring available within ADOC's segregation units and dangerous conditions inside the cells. Despite these dangers, ADOC does not have a meaningful mechanism that prevents mentally ill prisoners from being placed in segregation for lengthy periods of time. Moreover, many mentally ill prisoners land in segregation due to symptoms of mental illness. This combination of conditions is often deadly: most suicides in ADOC occur in segregation.

         For years, ADOC has failed to respond reasonably to these problems. Despite knowledge of serious and widespread deficiencies, it has failed to remedy known problems and exercised very little oversight of its mental-health care contractor. Associate Commissioner Naglich, who is in charge of contract monitoring, admitted that she has been aware of the contractor's deficient performance and inadequate quality-control process; however, she does not monitor the contractor to ensure that it provides minimally adequate care. Moreover, ADOC officials admitted on the stand that they have done little to nothing to fix problems on the ground, despite their knowledge that those problems may be putting lives at risk.

         The psychological and sometimes physical harm arising from these systemic deficiencies is palpable. Unidentified and under-treated mental illness causes needless pain and suffering in the form of persistent or worsening symptoms, decompensation, [6] self-injurious behavior, and suicide. The skyrocketing suicide rate within ADOC in the last two years is a testament to the concrete harm that inadequate mental-health care has already inflicted on mentally ill prisoners.

         In fact, as explained earlier, the court had a close encounter with one of the tragic consequences of inadequate mental-health care during the trial. Over the course of the trial, two prisoners committed suicide, one of whom was named plaintiff Jamie Wallace. Prior to his suicide, defendants' expert, Dr. Patterson, concluded based on a review of Wallace's medical records that the care he had received was inadequate. Dr. Haney, a correctional mental-health care expert, met Wallace months before his death, while he was housed in a residential treatment unit, and in his report expressed serious concerns about the care he was receiving.[7]Wallace's case was emblematic of multiple systemic deficiencies. Wallace testified, and his records reflected, that mental-health staff did not provide much in the way of consistent psychotherapeutic treatment, which is distinct from medications administered by nurses and cursory ‘check-ins' with staff. MHM clinicians recommended that he be transferred to a mental-health hospital, but ADOC failed to do so. His psychiatrist at the time of his death testified that the medically appropriate combination of supervised out-of-cell time and close monitoring when he was in his cell was unavailable due to a shortage of correctional officers. As a result, Wallace was left alone for days in an isolated cell in a treatment unit, where he had enough time to tie a sheet unnoticed; because his cell was not suicide-proof, he was able to find a tie-off point from which to hang himself.

         The case of Jamie Wallace is powerful evidence of the real, concrete, and terribly permanent harms that woefully inadequate mental-health care inflicts on mentally ill prisoners in Alabama. Without systemic changes that address these pervasive and grave deficiencies, mentally ill prisoners in ADOC, whose symptoms are no less real than Wallace's, will continue to suffer.

         2. Expert Witnesses

         Plaintiffs and defendants presented five experts in the correctional mental health and correctional administration fields.[8] By and large, experts from both sides agreed that ADOC facilities are suffering from severe systemic deficiencies that are affecting the delivery of mental-health care. For example, experts from both sides agreed that ADOC suffers from severe overcrowding; correctional understaffing; mental-health staff shortages; deficient treatment planning; inadequate psychotherapy; inadequate use of mental-health units; inappropriate placement of segregation inmates; and inappropriate use of segregation for mentally ill prisoners.

         Defendants' correctional mental-health care expert, Dr. Raymond Patterson, is a forensic psychiatrist who has worked for various state and federal correctional institutions as a provider and as a consultant. In preparation for his testimony, he reviewed the individual plaintiffs' medical records and deposition transcripts, visited and conducted audits of six facilities, and reviewed ADOC regulations, MHM policies and procedures, MHM monthly reports, and other expert reports. His conclusions regarding systemic deficiencies in ADOC's mental-health care system largely tracked those of Dr. Kathryn Burns, one of the plaintiffs' experts: he credibly concluded that ADOC needs more mental-health staff; ADOC's identification and classification of mental illness are inadequate; MHM's unlicensed practitioners should be supervised; treatment planning is deficient; too few patients are getting inpatient care; ADOC should provide hospitalization as an option for the most severely ill patients; and suicide prevention measures are inadequate.[9]

         Defense expert Robert Ayers is a correctional administration expert who has been involved in the California prison system for over 40 years. In preparation for giving his opinion, Ayers reviewed plaintiffs' expert reports, visited six facilities, and talked with ADOC and MHM staff during those visits. He agreed with plaintiffs' experts that ADOC facilities are understaffed and overcrowded. He opined that ADOC's written policies related to mental-health care seemed to be adequate. However, he credibly explained that, mainly due to the severe understaffing and the lack of documentation, he had reasons to doubt that correctional officers and mental-health staff were actually complying with ADOC policies and procedures. He also concluded that ADOC was not providing an adequate level of care to all prisoners with mental-health needs.

         Dr. Kathryn Burns, the chief psychiatrist for the Ohio Department of Rehabilitation and Correction, is a correctional mental-health expert for the plaintiffs. To prepare for her testimony, Dr. Burns visited nine major ADOC facilities, touring housing units, mental-health treatment areas, and crisis cells; she held formal interviews with 77 prisoners and spoke to an additional 25 prisoners at cell-front; she also reviewed documents such as medical records, ADOC regulations, MHM's quality-improvement (or ‘continuous quality improvement' or ‘CQI') and multidisciplinary-team meeting minutes, suicide tracking sheets, and audit results. Based on her review of this evidence, she identified a wide range of problems in the delivery of mental-health care, including: insufficient mental-health staffing and correctional staffing; inadequate identification and classification of mental illness; inadequate treatment, including cursory counseling appointments, inadequate treatment plans, dearth of group counseling, and inadequate use of mental-health units; and inadequate response to self-injurious behavior and mental-health crises. Dr. Burns credibly opined that these inadequacies, separately and taken together, subject mentally ill prisoners to a substantial risk of harm from untreated symptoms, continued pain and suffering, decompensation, self-injurious behavior, and suicide.

         Dr. Craig Haney, a professor of psychology at the University of California Santa Cruz, is an expert for the plaintiffs in the psychological effects on prisoners of incarceration and particularly of segregation. His testimony focused on the state of segregation units and their impact on prisoners' mental health, based on his visits to seven facilities, interviews with numerous prisoners, and review of documents such as deposition transcripts of ADOC and MHM personnel, medical records, monthly statistical reports, and quality-assurance documents, among others. He testified that segregation units he saw were “degraded, dilapidated, deplorable, ” and that these units and conditions have a significant negative psychological impact on prisoners. Haney Testimony at vol. 1, 79. Furthermore, he explained how ADOC's segregation practices harm mental health of all prisoners, and especially that of prisoners who are already mentally ill.

         Lastly, plaintiffs' expert Eldon Vail is a correctional administration expert who has worked in corrections for over 30 years. Vail toured seven prisons, spending a day at each, and conducted confidential interviews with 42 prisoners. He also reviewed ADOC policies and procedures, meeting minutes, reports and logs generated by ADOC, deposition testimony of ADOC and MHM personnel, and other documentary evidence. His testimony focused on matters of prison administration, including security, staffing, and behavior management, and the impact of these factors on the provision of mental-health care and on prisoners' mental health. He credibly testified that the level of correctional understaffing at ADOC was so low as to be “shocking, ” and that it has cascading effects on mental-health care: inadequate staff to transport prisoners to appointments and supervise treatment activities; inadequate staff to monitor segregation inmates, who have higher suicide risks; and overcrowded crisis cells filled with prisoners who feel unsafe due to violence in general-population dorms. Vail Testimony at vol. 1, 34.

         IV. EIGHTH AMENDMENT LEGAL STANDARD

         The Eighth Amendment's prohibition on “cruel and unusual punishments” extends to a State's failure to provide minimally adequate medical care that “may result in pain and suffering which no one suggests would serve any penological purpose.” Estelle v. Gamble, 429 U.S. 97, 103 (1976); Harris v. Thigpen, 941 F.2d 1495, 1504 (11th Cir. 1991) (“Federal and state governments ... have a constitutional obligation to provide minimally adequate medical care to those whom they are punishing by incarceration.”). The State's obligation to provide medical care to prisoners includes psychiatric and mental-health care. Rogers v. Evans, 792 F.2d 1052, 1058 (11th Cir. 1986) (“Failure to provide basic psychiatric and mental-health care states a claim of deliberate indifference to the serious medical needs of prisoners.”). The ‘basic' mental-health care that States must provide if needed by a prisoner includes not only medication but also psychotherapeutic treatment. See Greason v. Kemp, 891 F.2d 829, 834 (11th Cir. 1990) (“Even if this case involved failure to provide psychotherapy or psychological counselling alone, the court would still conclude that the psychiatric care was sufficiently similar to medical treatment to bring it within the embrace of Estelle.”). The State's obligation remains even if it has contracted with private parties to provide medical care. West v. Atkins, 487 U.S. 42, 56 (1988). That is, the State is liable for the contractor's unconstitutional policies and practices if the contractor is allowed to determine policy either “expressly or by default.” Ancata v. Prison Health Servs., Inc., 769 F.2d 700, 706 n.11 (11th Cir. 1985).

         To prevail on an Eighth Amendment challenge, plaintiffs must prove that prison officials acted with deliberate indifference to serious medical needs. Estelle, 429 U.S. at 105-06. This inquiry consists of both objective and subjective tests. The objective test requires showing that the prisoner has “serious medical needs, ” Estelle, 429 U.S. at 104, and either has already been harmed or been “incarcerated under conditions posing a substantial risk of serious harm.” Farmer v. Brennan, 511 U.S. 825, 834 (1994). Subjectively, a prisoner must show that a prison official acted with deliberate indifference to that harm or risk of harm: that is, the official must have “known[] of and disregarded[] an excessive risk to inmate health or safety.” Id. at 837; see also Farrow v. West, 320 F.3d 1235, 1245 (11th Cir. 2003).

         V. FINDINGS OF FACT AND CONCLUSIONS OF LAW

         In this section, the court first discusses the basis for its finding that the plaintiffs have serious mental-health needs that require mental-health treatment. The court then lays out the common factors contributing to the substantial risks of harm in ADOC: shortages of mental-health staff, understaffing of correctional officers, and overcrowding. After that, the court proceeds through seven different ways in which ADOC's mental-health care system has caused actual harm and a substantial risk of serious harm; the treatment of mentally ill prisoners at Tutwiler; issues on which the court does not, at this time, find for the plaintiffs; and the defendants' knowledge of such harm and risks, and their failure to act in a reasonable manner to mitigate those risks. The section concludes with a discussion of the defendants' legal defenses based on Ex parte Young, 209 U.S. 123 (1908).

         A. Serious Mental-Health Needs

         To prove an Eighth Amendment claim based on inadequate mental-health care, plaintiffs must show that they have serious mental-health care needs. A serious need is “one that has been diagnosed by a physician as mandating treatment or one that is so obvious that even a lay person would easily recognize the necessity for a doctor's attention.” Farrow v. West, 320 F.3d 1235, 1243 (11th Cir. 2003). Thus, courts may find the existence of serious needs even when prison staff have failed to recognize an inmate's need for treatment. Danley v. Allen, 540 F.3d 1298, 1310-11 (11th Cir. 2008) (finding that plaintiff, whose requests to see a nurse had been rebuffed, demonstrated a serious medical need in that he had difficulty breathing and swollen, burning eyes, and a fellow inmate brought his condition to the attention of correctional officers), overruled on other grounds, Randall v. Scott, 610 F.3d 701, 709 (11th Cir. 2010). A serious mental-health care need was found where a doctor, nurse, and correctional officials recognized that a prisoner “engaged in self harm” and “showed outward signs of mania and depression.” Jacoby v. Baldwin Cty., 596 F. App'x 757, 763 (11th Cir. 2014).

         One of the factors that courts consider in finding a serious medical need is “whether a delay in treating the need worsens it.” Danley, 540 F.3d at 1310. “The tolerable length of delay in providing medical attention depends on the nature of the medical need and the reason for the delay.” Hill v. Dekalb Reg'l Youth Det. Ctr., 40 F.3d 1176, 1188 (11th Cir. 1994) (citation omitted). Factors relevant to determining the tolerable length of delay include the “seriousness of the medical need, ” “whether the delay worsened the medical condition, ” and “the reason for delay.” Id. at 1189.

         Because this is a Rule 23(b)(2) class action lawsuit challenging defendants' actions “on [a] ground[] that appl[ies] generally to the class”--that is, defendants' provision of inadequate mental-health care--the plaintiffs must show that serious mental-health needs exist on a system-wide basis, rather than on an individual basis.[10] Fed.R.Civ.P. 23(b)(2). As explained in the class-certification opinion, the plaintiffs' claim and the remedies they seek are systemic. Braggs v. Dunn, 318 F.R.D. 652, 667 (M.D. Ala. 2016). In other words, “plaintiffs are not seeking adjudication of demands for particular individualized treatment, ” and any relief the court grants “would be appropriate for everyone subjected to the substantial risk of serious harm plaintiffs claim [ADOC's inadequate mental-health care system] creates--that is, prisoners with serious mental illness.” Id. at 668.

         It is clear that a number of prisoners in ADOC's custody have serious mental-health needs, and the issue is undisputed. As a preliminary matter, MHM places prisoners on the caseload only if they have been diagnosed with a condition that requires treatment. Therefore, all prisoners on the caseload meet the legal requirement for having a serious mental-health need. Prisoners on the mental-health caseload have wide-ranging illnesses, such as bipolar disorder, schizophrenia, schizoaffective disorder, major depressive disorder, mood disorders, borderline personality disorder, anxiety, and PTSD.[11]

         Furthermore, the court heard testimony from multiple prisoners, both named plaintiffs and class members, who clearly exhibited serious mental-health needs. For example, plaintiff R.M. has been diagnosed with paranoid schizophrenia and admitted that he is out of touch with reality; he testified to what were obviously his delusions regarding his blood relationships to three different well-known terrorist figures and his owing billions of dollars to the United States treasury. Similarly, medical records made clear that plaintiff Q.B. has suffered from years of delusion and hallucination; he was on involuntary psychiatric medication orders for years while in ADOC custody. Lastly, as explained earlier, plaintiff Jamie Wallace[12] had been diagnosed with bipolar disorder and schizophrenia, among other mental-health conditions, and he testified that he heard voices of his deceased mother telling him to cut himself. In sum, plaintiffs presented more than sufficient evidence establishing their serious mental-health needs. Because only prisoners with serious mental-health needs have a cognizable Eighth Amendment claim, when the court refers to ‘mentally ill prisoners' in this opinion, it is referring to only those with serious mental-health needs.

         B. Serious Harm and Substantial Risks of Serious Harm Posed by Inadequate Care

         In addition to showing a serious medical need, plaintiffs must establish that they have been subjected to serious harm, or a substantial risk of serious harm--the second part of the ‘objective' test under the Eighth Amendment jurisprudence--as a result of inadequate mental-health care. Put another way, plaintiffs must show that their serious medical need, “if left unattended, ‘poses a substantial risk of serious harm.'” Farrow v. West, 320 F.3d 1235, 1243 n.13 (11th Cir. 2003)(quoting Farmer v. Brennan, 511 U.S. 825, 834 (1994)). Defendants may be held liable for “incarcerating prisoners under conditions posing a substantial risk of serious harm.” Farmer, 511 U.S. at 834.[13]

         The “serious harm” requirement “is concerned with both the ‘severity' and the ‘duration' of the prisoner's exposure” to the harm, such that an exposure to harm “which might not ordinarily violate the Eighth Amendment may nonetheless do so if it persists over an extended period of time.” Chandler v. Crosby, 379 F.3d 1278, 1295 (11th Cir. 2004) (citation omitted). While mere discomfort is insufficient to support liability, id., “unnecessary pain or suffering” qualifies as serious harm. LaMarca v. Turner, 995 F.2d 1526, 1535 (11th Cir. 1993).

         Plaintiffs may bring an Eighth Amendment challenge to a condition that is already inflicting serious harm on them at the time of the complaint or to prevent serious harm which is substantially likely to occur in the future--a substantial risk of serious harm. As the Supreme Court explained in Helling v. McKinney, 509 U.S. 25 (1993), a case in which a prisoner challenged his prolonged exposure to second-hand smoke, “a remedy for unsafe conditions need not await a tragic event, ” because “the Eighth Amendment protects against future harms to inmates, ” even when the harm “might not affect all of those exposed” to the risk and even when the harm would not manifest itself immediately. Id. at 33-34. In other words, plaintiffs must show “that they have been subjected to the harmful policies and practices at issue, not (necessarily) that they have already been harmed by these policies and practices.” Dunn v. Dunn, 219 F.Supp.3d 1100, 1123 (M.D. Ala. 2016)(Thompson, J.). In the class-action context, the plaintiff class must show that it, as a whole, has been subjected to policies and practices that create a substantial risk of serious harm. Braggs v. Dunn, 317 F.R.D. 634, 654 (M.D. Ala. 2016)(Thompson, J.).

         Moreover, multiple policies or practices that combine to deprive a prisoner of a “single, identifiable human need, ” such as mental-health care, can support a finding of Eighth Amendment liability. Gates v. Cook, 376 F.3d 323, 333 (5th Cir. 2004) (“Conditions of confinement may establish an Eighth Amendment violation ‘in combination' when each would not do so alone, but only when they have a mutually enforcing effect that produces the deprivation of a single, identifiable human need such as food, warmth, or exercise--for example, a low cell temperature at night combined with a failure to issue blankets.”)(citing Wilson v. Seiter, 501 U.S. 294, 304 (1991)). The Eleventh Circuit Court of Appeals has recognized this ‘totality of conditions' approach in prison-conditions cases. See, e.g., Hamm v. DeKalb Cty., 774 F.2d 1567, 1575-76 (11th Cir. 1985).

         Mentally ill ADOC prisoners, defined here as prisoners with serious mental-health needs, have suffered harm and are subject to a substantial risk of serious harm due to ADOC's inadequate mental-health care. Based on the trial testimony, the court finds seven interrelated areas of inadequacy: (1) identification and classification of prisoners with mental illness; (2) treatment planning; (3) psychotherapy; (4) inpatient mental-health care units; (5) crisis care and suicide prevention; (6) use of disciplinary actions for symptoms of mental illness; and (7) use of segregation for mentally ill prisoners. In all seven areas, experts from both sides by and large agreed about significant flaws affecting mentally ill prisoners.[14] MHM and ADOC staff also recognized and corroborated the existence and severity of these issues. Even Associate Commissioner Naglich essentially agreed that some of these were problems so significant that they must be fixed as soon as possible, because lives are at risk.[15] These inadequacies, alone and in combination, subject mentally ill prisoners to actual harm and a substantial risk of serious harm--including worsening of symptoms, increased isolation, continued pain and suffering, self-harm and suicide.

         1. Contributing Conditions

         Three conditions contribute to all of the deficiencies in ADOC's treatment of mentally ill prisoners: understaffing of mental-health care providers, understaffing of correctional officers, and overcrowding.[16] Associate Commissioner Naglich and defendants' expert witnesses largely agreed with plaintiffs that these conditions present significant challenges to the system today. Correctional and mental-health understaffing, both alone and in combination, impose substantial risks of serious harm to mentally ill prisoners, and overcrowding compounds these risks.

         a. Overcrowding

         ADOC facilities are significantly and chronically overcrowded. Publically available information on ADOC's inmate population and capacity plainly lays out the magnitude of overcrowding: ADOC's September 2016 monthly statistical report states that ADOC held 23, 328 prisoners in facilities that are designed to hold only 13, 318; this brings the occupancy rate to over 175 %. Pl. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 2, 4.[17] Plaintiffs' expert Vail testified that the magnitude of overcrowding in ADOC is the worst he has seen in his career in corrections and consulting for other correctional systems across the country. According to Vail, California, whose overcrowded correctional system was found to be unconstitutional, approached an occupancy rate of 170 %; a three-judge court subsequently ordered the State to lower the occupancy rate to 137.5 %, a target rate that was affirmed by the Supreme Court. Brown v. Plata, 563 U.S. 493, 539-42 (2011). The sheer magnitude of overcrowding within ADOC has meant that some ADOC facilities, including Kilby, Bibb, Staton, and Easterling, house more than double the number of prisoners they are designed to hold. Pl. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 4. Even maximum-security facilities use open-bay dormitories filled with wall-to-wall rows of double bunk beds, holding up to 240 prisoners in a single room, where officers do not have a line of sight on most of the prisoners they are assigned to supervise.

         b. Mental-Health Understaffing

         ADOC has maintained mental-health staffing levels that are chronically insufficient across disciplines and facilities. Witness after witness identified significant mental-health staffing shortages as one of the major reasons for ADOC's inability to meet the rising mental-health care needs of prisoners. Most significantly, Associate Commissioner for Health Services Naglich admitted that MHM has been understaffed since 2013 and remains understaffed today. MHM's program director Houser stated bluntly that MHM staffing shortages make it difficult to “do the work required under the contract, ” and that the current caseload for MHM staff does not meet an “acceptable standard.” Houser Testimony at vol. 2, 24-25.

         Over the course of the trial, evidence showed that the mental-health caseload per MHM provider has been increasing since 2008, largely due to three reasons: (1) an increasing number of prisoners with mental-health needs across ADOC; (2) multiple budget cuts over the years; and (3) ADOC's long-time refusal to increase the authorized number of mental-health staff positions despite repeated requests from MHM, even when an initiative to transfer some of the caseload to ADOC staff--so-called ‘blending of services'--was not implemented as planned.[18]

         ADOC's prisoner population has had increasing needs for mental-health services over the last decade. As multiple MHM providers and expert witnesses from both sides testified, ADOC's prisoner population has become more mentally ill over the last decade, both in terms of the number of individuals who need mental-health care and in terms of the acuity of mental-health care needs. MHM's medical director, Dr. Hunter, testified that the number of prisoners receiving regular mental-health services within ADOC (also known as being ‘on the caseload') has been increasing since 2003, which has been “concerning” and “tax[ing his] ability to adequately do” what he is required to do under the contract. Hunter Testimony at ___. (For transcripts that are not yet finalized, the court leaves the page numbers blank.) He also explained that, since 2003, the number of prisoners coming into the system with severe mental illness has been increasing. MHM's own documents showed that between 2008 and 2016, the mental-health caseload increased by 25 % across all facilities. Pl. Dem. Ex. 25, Pricing, Caseload and Staffing Comparison Over Time (doc. no. 1071-5).

         As the need for mental-health services has been increasing substantially, MHM and ADOC have been hiring fewer and fewer providers over the years, exacerbating the staffing shortage. In 2009, ADOC reduced MHM's compensation under the contract and the number of authorized positions to be hired by MHM. In 2013, the state legislature further reduced ADOC's mental-health care budget by 10 %. ADOC and MHM then re-negotiated their 2013 contract to reduce the previously agreed-upon “minimum required staffing, ” cutting close to 20 full-time equivalent positions. Naglich Testimony 2-211; Pl. Dem. Ex. 140, MHM Staffing Increase Chart (doc. no. 1148-59); see also Pl. Dem. Ex. 25, Pricing, Caseload, and Staffing Comparison Over Time (doc. no. 1071-5). During that same contract renewal period, ADOC and MHM also reduced the number of positions that are covered by the contractual ‘staffing rebate' provision, under which MHM must pay back ADOC if it does not fill all authorized positions. In other words, the revision allowed MHM to leave clinical staff positions unfilled without being penalized, even though the overall number of authorized positions had already been reduced. Houser described this latter modification as a way to make the reduction in payment and staffing under the contract “more palatable for MHM.” Houser Testimony at vol. 1, 49.

         Another driving force behind MHM's mental-health understaffing is ADOC's failure to implement the ‘blending of services' initiative successfully. Houser explained that this initiative was established in 2009 in response to ADOC's reduction in both the amount it would pay to MHM under the contract and in the staffing provided for in the contract: MHM's caseload would be reduced by transferring treatment of prisoners with lower-acuity mental-health issues to ADOC's psychological associates; the initiative was an “attempt to make sure that the inmates received mental health services” despite the staffing reduction and increasing caseloads. Houser Testimony at vol. 1, 14. However, ADOC failed to implement the initiative across its facilities: MHM's staffing was reduced, but at many facilities, psychological associates did not take over any caseload from MHM. Naglich explained that, because some wardens were resistant to letting psychological associates carry significant caseloads, MHM staff remained responsible for most of the patients, even though there were now fewer MHM providers than before. Houser testified that blending of services is not currently happening anywhere in ADOC in the way it was designed to happen, despite MHM's reduced staffing levels. ADOC's chief clinical psychologist Dr. David Tytell admitted that the initiative has failed to work. However, ADOC has not restored MHM's staffing to the pre-2009 level.[19]

         The result of ADOC's refusal to increase MHM's staffing level or even to restore staffing to the pre-2009 level has been chronic shortages of mental-health care providers. Dr. Hunter testified that the staffing shortage has had a significant impact on scheduling of psychiatric visits and medication management. Several mental-health counselors testified that their caseloads have soared; Houser testified that MHP caseloads at some facilities have been twice what they should be, which is “never an acceptable standard.” Houser Testimony at vol. 2, 25. Increasing caseloads due to understaffing have also led to a high turnover rate among staff: according to Houser, staff resign because of their frustration with increasing caseloads, leaving the rest of the staff with even higher caseloads; recruiting also suffers because of the overwhelming caseloads that mental-health staff are expected to manage. MHM's monthly operating report submitted to ADOC for May 2016 described the problem in stark terms: “Mental health caseloads are running high at many of the facilities. Staff has attempted to accommodate the increased numbers, however quality cannot be maintained at current staffing levels.” Joint Ex. 343 (doc. no. 1038-702) at 19. As explained in more detail in the following sections, this understaffing also has prevented MHM from providing care that complies with ADOC's administrative regulations, the contract, and professional standards for minimally adequate care in a prison system.[20]

         Not surprisingly, experts from both sides opined that ADOC does not have a sufficient number of mental-health staff for a system of its size. Dr. Patterson, the defense expert, concluded based on his review of medical records and site visits that ADOC's mental-health care system is significantly understaffed. Plaintiffs' expert Dr. Burns agreed with this assessment based on her review of medical records and MHM internal records, which revealed that caseloads for psychiatric providers and counselors were too large to allow for sufficient counselling or therapeutic group activities. Dr. Burns concluded that ADOC needs more psychiatric staff, psychologists, registered nurses, and activity technicians.[21]

         MHM's corporate office--which exercises contract-compliance oversight but does not directly provide care in Alabama--has repeatedly raised mental-health understaffing in the annual clinical contract-compliance review reports (hereafter ‘contract-compliance reports') sent to Associate Commissioner Naglich's Office of Health Services. Starting in 2011, each annual contract-compliance report included information on multiple facilities that were suffering from staffing shortages, “compromising [MHM's] ability to provide monthly follow-up for all caseload inmates.” Pl. Ex. 1190, 2011 Contract-Compliance Report (doc. no. 1070-8) at 15. The 2013 report also noted the impact of the staffing reduction that year, stating that “[d]espite the increase in the size of the caseload across ADOC, MHM's contract has been compressed to include significant staffing cuts at all sites.” Pl. Ex. 114, 2013 Contract-Compliance Report (doc. no. 1070-4) at 1. The report also warned that, at Donaldson, where one of the two male residential treatment units is located, “[c]urrent staffing pattern does not support the delivery of adequate services to inmates and that they have been reduced to providing minimal and ‘triage-based' services rather than effective and thoughtfully planned treatment.” Id. at 5. In 2016, MHM reported significant backlogs in treatment and staffing shortages at Donaldson and Bullock, the two male facilities that house ADOC's most seriously ill mental-health patients. Pl. Ex. 115, 2016 Contract-Compliance Report (doc. no. 1070-5). Even after the partial staffing increase in September 2016, Houser stated that MHM remains understaffed and pointed to mental-health understaffing as a cause for a plethora of issues, including insufficient identification of mental illness at intake and referrals; missed counseling appointments and group sessions; and inadequate monitoring of prisoners in mental-health crises.

         Based on Associate Commissioner Naglich's testimony and other evidence, the court finds that MHM has been consistently and significantly understaffed at least since 2013, and that it is still understaffed even after ADOC approved a small staffing increase in September 2016 as part of its one-year contract extension.

         c. Correctional Understaffing

         In addition to mental-health understaffing and overcrowding, a significant shortage of correctional officers also hinders the delivery of mental-health care and poses a substantial risk of harm to prisoners who need mental-health care. As with mental-health staffing shortages, witness after witness, including both defendants, testified that a significant shortage of correctional officers has been one of the biggest obstacles to providing mental-health care in ADOC. In Associate Commissioner Naglich's words, the problem of insufficient mental-health staffing is “compounded by” the lack of sufficient correctional staffing at ADOC. Naglich Testimony at vol. 2, 208.

         ADOC has reported an ever-increasing shortage of correctional officers in its annual reports and monthly operating reports since 2006. In 2010, ADOC summarized that “[c]orrectional staffing continues to fall short of required levels--impacting the inmate to officer ratio and overtime necessary to cover essential posts, ” and reported that the shortage rate was 12.2 % at close-custody (highest security) facilities and 21.2 % at medium-security facilities. Joint Ex. 463, Vail Expert Report (doc. no. 1038-1048) at 39 (quoting ADOC Annual Report FY 2010). Essentially the same statement regarding the officer shortage appeared in every annual report until 2013, when the shortage rate across facilities shot up to 43.3 %. The report in 2015 showed officer shortage rates of over 25 % at 13 of the 15 major prisons and over 50 % at six of those; the highest was 68 % at Bibb. Donaldson was barely under 25 %; only one prison, Hamilton, the facility for the elderly and the infirmed, was below 25 %. Id. at 39-40 (citing ADOC Annual Report FY 2013, 2015). As of September 2016, ADOC reported having filled only about half of the authorized positions for correctional officers. Pl. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 16 (showing 51.1 % overall staffing level).[22] The staffing level continued to drop throughout 2016, according to Associate Commissioner of Operations Grantt Culliver.

         Understaffing has been a persistent, systemic problem that leaves many ADOC facilities incredibly dangerous and out of control. Defendants' correctional administration expert Robert Ayers observed multiple high-security units not being monitored at all and an entire unit at Bibb overseen by a single control booth officer and a single officer on the floor; he opined that such understaffing was “not acceptable.” Ayers Testimony at ___. Plaintiffs' correctional administration expert Vail agreed with this conclusion and elaborated that many facilities are struggling to have sufficient numbers of correctional officers to station at least one officer per dorm--including the highest-security facilities, such as Holman and Kilby. Not surprisingly, a severe shortage of officers leads to dangerous and violent conditions, especially in high-security facilities with overcrowded dormitories.[23] In these conditions, prisoners and correctional officers alike are justifiably afraid for their safety--a jarring image that many prisoner-witnesses and experts painted in their testimony. For example, class member M.P., who is now housed in Ventress, stated repeatedly how dangerous it was to be in a general-population dorm at St. Clair; he was enormously relieved to be transferred to another prison.[24]Multiple experts also testified that during their site visits, prison officials did not allow them to enter certain parts of the prison, such as the second and third tiers of the Holman segregation unit and a whole half of Bibb, because the officials could not guarantee their safety.[25]

         As a result of the officer shortage, ADOC has an exceedingly high overtime rate. Overtime rate refers to the proportion of the number of hours worked by correctional officers as overtime compared to the total number of hours worked. A high overtime rate undermines security and officer morale, which in turn has negative implications for mental-health care. ADOC's chief of staff Steve Brown admitted that the current overtime rate of over 20 % is not sustainable in the long run, because it decreases retention of officers and increases the number of disciplinary actions against officers. Multiple vulnerability analyses--ADOC's internal critical assessments of each facility's security risks--also found that mandatory overtime and overuse of overtime have affected staff morale and contributed to high turnover rates. Pl. Ex. 146, Bullock Vulnerability Analysis (doc. no. 1087-3); Pl. Ex. 185, Donaldson Vulnerability Analysis (doc. no. 1087-6); Pl. Ex. 204 Elmore Vulnerability Analysis (doc. no. 1087-8).[26]

         This chronic and severe correctional understaffing has compromised mental-health care in many ways. Most significantly, as discussed in more detail in Part V.B.4, correctional officers are needed to provide security for mental-health programming and escort prisoners from their cells to appointments if they are not in general population. Due to insufficient correctional staffing, appointments and group activities are frequently canceled and delayed, significantly impairing MHM staff's ability to provide treatment. See, e.g., Pl. Ex. 115, 2016 Contract-Compliance Report (doc. no. 1070-5) at 3 (MHM staff not being able to access patients at Bullock, Donaldson, Holman, St. Clair, and Staton due to correctional staffing shortages, and expressing concern about their own safety at five facilities); Pl. Ex. 105, 2014 MHM Implementation Review Report (doc. no. 1070-3) at 3 (20 to 70 % of mental-health appointments were canceled due to correctional officer shortages at the Donaldson residential treatment unit in 2014). Based on the testimony of Ayers, one of the defense experts, and almost all MHM providers and managers who testified, the court is convinced that the correctional staffing level falls intolerably short of providing adequate care to prisoners who need to be escorted to their mental-health appointments.

         Second, understaffing impacts correctional officers' ability to supervise mentally ill prisoners effectively. According to plaintiffs' expert Vail, understaffing compromises overworked correctional officers' alertness and ability to respond to incidents, crises, and emergencies, and to exercise the patience and restraint necessary to supervise mentally ill prisoners. This effect is even more pronounced in segregation and crisis cells. Without sufficient correctional staff, officers are unable to check on prisoners isolated from the rest of the population as frequently as they must in order to guarantee their safety. As a result, decompensating prisoners go unnoticed, leading to extended suffering without access to treatment, and more frequent crisis situations.

         Correctional understaffing, combined with overcrowding, also has a more direct impact on prisoners' mental health. The combination of overcrowding and understaffing leads to an increased level of violence, both because of the difficulty of diffusing tension and violence in an overcrowded open-dormitory setting, and because of the lack of supervision by correctional officers. See Pl. Ex. 1260, ADOC September 2016 Monthly Statistical Report (doc. no. 1108-37) at 12 (reporting nearly 200 assaults with serious injuries and seven homicides in the fiscal year ending in September 2016). According to Dr. Haney, plaintiffs' expert on correctional mental health and solitary confinement, prisoners' legitimate fear of violence is a common source of anxiety and mental instability: for prisoners who already suffer from mental illnesses, this environment increases their likelihood of decompensation. The level of danger and lack of control arising from overcrowding and insufficient staffing also contributes to a punitive culture, in which officers prioritize security concerns over mental-health treatment and are quick to treat mental-health symptoms as behavioral problems; dealing with violence and emergencies also diverts correctional resources away from regular mental-health programming and treatment. Untreated or undertreated mental illness in turn creates a greater need for mental-health services, provision of which is limited by the very shortage of officers that created the increased need in the first instance. Furthermore, mental-health problems are much more likely to go unnoticed in overcrowded and understaffed prisons, because correctional officers who are spread too thin are less likely to notice any unusual behavior by a particular prisoner. These observations made by Dr. Haney all rang true in the evidence before the court. Lastly, as Dr. John Wilson, a psychologist who serves as one of the directors of MHM's national Clinical Operations Department, explained to MHM's program director Houser, “experience and research” confirm that suicides tend to increase with overcrowding, and “basic unrest at a systems level” can cause a spike in suicides. Pl. Ex. 1224, October 1, 2015 Email from Wilson to Houser (doc. no. 1117-24) at 2. In fact, the suicide rate within ADOC has more than doubled in the last two years, as ‘unrest at a systems level' continues to plague ADOC facilities. Taken together, ADOC's low correctional-staffing level, in the context of its severely overcrowded prisons, creates a substantial risk of serious harm to mentally ill prisoners, including continued pain and suffering, decompensation, self-injury, and suicide.

         2. Identification and Classification of Prisoners' Mental-Health Needs

         As one expert put it, ADOC's mental-health care system “falls apart at the door”: the system fails to identify and classify appropriately those with mental illnesses, and the effect of this under-identification cascades through the system. Haney Testimony at vol. 1, 30. Because of inadequate identification and classification, seriously mentally ill prisoners languish and decompensate in ADOC without treatment, ending up in crisis care and engaging in destructive--sometimes fatal--self-harm.

         Timely identification and appropriate classification of prisoners with mental illness are essential to a functioning mental-health care system. As experts explained, and as common sense would dictate, mental-health treatment cannot begin unless providers are aware of who needs treatment and for what. Failure to identify those who need mental-health services denies them access to necessary treatment, creating a substantial risk of harm to those who remain unidentified. See LaMarca v. Turner, 995 F.2d 1526, 1544 (11th Cir. 1993) (affirming conclusion that systematic denial of access to treatment constitutes deliberate indifference to a serious medical need).

         a. Inadequate Intake Process

         ADOC's system for identifying prisoners with mental illness is significantly inadequate. According to three experts--defense expert Patterson and plaintiffs' experts Burns and Haney--the percentage of prisoners within ADOC with mental illness (referred to as the ‘prevalence rate') is substantially lower than the national average: the average rate of mental illness for men in correctional systems ranges between 20 % and 30 %; ADOC's prevalence rate is between 14 % and 15 %. See Joint Ex. 346, June 2016 MHM Monthly Statistical Report (doc. no. 1038-708) at 1.

         As experts from both sides testified, ADOC's prevalence rate is abnormally low and reflects that the system is under-identifying prisoners with mental illness. Defense expert Dr. Patterson explained that experts do not expect to see much variation in actual prevalence rates across correctional systems, and that he has not seen anything that suggests that ADOC would have a lower prevalence rate than other correctional systems for any reason other than under-identification. Dr. Burns agreed and explained that it is highly likely that the abnormally low prevalence rate is due to under-identification, rather than because Alabama prisoners have fewer mental-health issues compared to those in other States. She added that she does not know of any States that have lower prevalence rates than Alabama. Assuming that ADOC's actual prevalence rate for mental illness actually tracks the national figure of between 20 % and 30 %, somewhere between 1, 200 and 3, 600 prisoners should be receiving mental-health care but are not, because between 5 % and 15 % of ADOC's 24, 000 prisoners have not been identified as having a mental illness.

         A closer examination of the two main processes of identifying prisoners with mental-health care needs--intake and referral--sheds light on why ADOC's prevalence rate is so low. First, ADOC's mental-health screening process at intake fails to identify a substantial number of prisoners with mental-health issues. Licensed practical nurses, who have very limited training, are responsible for conducting mental-health screening for prisoners at intake at Kilby (for all male prisoners) and Tutwiler (for all female prisoners). No higher-level provider supervises the LPNs during the intake process. The intake LPN fills out forms and questionnaires and decides whether to refer a prisoner for further examination by a psychiatrist or a nurse practitioner. If the LPN determines that a prisoner does not need to be referred to a psychiatrist or nurse practitioner, a mental-health code of MH-0, denoting no need for mental-health care, is entered into the system. Prisoners who are designated as MH-0 by an LPN do not receive any further evaluation or any mental-health treatment unless referred to mental-health services later by a staff member or the prisoners themselves. On the other hand, if the LPN refers the prisoner for evaluation, a psychiatric provider completes an evaluation, gives a diagnosis if appropriate, and assigns a mental-health code, which determines the level of care the prisoner subsequently receives and ranges from MH-0 (no mental-health need) to MH-6 (in need of hospitalization).[27]

         Experts from both sides agreed, and the court finds, that the intake screening process conducted by an LPN without any on-site supervision by a higher-level provider contributes to under-identification of prisoners with mental illness. This is because LPNs, who only have 12 to 15 months of general medical training--very little of which may be related to mental health--are not qualified to assess the presence or acuity of mental illness symptoms based on information obtained during the intake process. Intake forms that LPNs fill out include questions that require clinical assessments, rather than simple yes-or-no questions based on physical observations. See Joint Ex. 85, Admin. Reg. § 601 Mental Health Forms and Disposition (doc. no. 1038-106); Burns Testimony at vol. 1, 44-45. According to the experts, LPNs are not qualified to make such clinical assessments. Moreover, although LPNs may make referrals based on self-reported symptoms of mental illness, a proper intake system cannot solely rely on self-reporting to identify mental-health needs. As Dr. Burns testified, the use of unsupervised LPNs for intake mental-health screening presents an “obvious” risk of under-identification. Burns Testimony at vol.1, 61-62.[28]

         The use of inadequately supervised LPNs for intake is compounded by insufficient mental-health staffing. Houser testified that MHM does not have sufficient staffing or space to conduct mental-health screenings at Kilby (where all male prisoners are screened), and her staff have had to send prisoners to other facilities without conducting the initial intake screening. This in turn has increased the workload for mental-health staff at the receiving facilities and has created delays in the provision of mental-health care to those who need treatment. Dr. Patterson, the defense expert, agreed that insufficient staff at intake has led to insufficient identification of prisoners with mental illness, and that this failure to identify increases the risk of continued pain and suffering and potential suicides among those who are not receiving the mental-health care they need.

         b. Inadequate Referral Process

         The other mechanism for identifying and classifying prisoners with mental illness, the referral process, is riddled with delays and inadequacies. The purpose of the referral process is to identify prisoners whose mental illnesses develop during their incarceration and prisoners whose mental-health needs were not identified during the intake process. Furthermore, the referral process enables the system to respond to the changing mental-health needs of prisoners as they arise, regardless of their initial mental-health assessment results. In a functioning system, referrals from prisoners or staff would be triaged based on the urgency of the articulated needs: some may warrant immediate action, such as placement in a suicide-watch cell or an immediate evaluation by a psychiatrist, while others may be addressed over a longer period of time. According to Dr. Patterson, the defense expert, triaging is important because the assessment process enables clinicians to determine appropriate next steps, and delays in doing so pose a risk of untreated symptoms, including a risk of death from critical yet unmet treatment needs.

         As with the intake screening procedure, experts from both sides concluded that ADOC's referral process suffers from serious deficiencies. First, ADOC does not have a system to triage and identify the urgency of each request, and to make referrals according to the level of urgency. MHM's contract-compliance reports have identified this issue year after year, starting in 2011: the reports stated that processed referral slips did not reflect acuity levels, and the logs of referrals did not record the relevant date and time information, making it impossible to ensure timely processing and referrals. Despite perennial indications that referral requests were being processed in a haphazard manner, ADOC still does not have any system of tracking and processing referrals to ensure that urgent requests are actually referred to providers, or that providers are able to handle requests in a timely fashion: an audit performed by defense experts in May 2016 revealed that referral forms still do not note urgency levels that would enable triaging.[29]Second, the referral process is inadequate because correctional officers are ill-positioned to notice behavioral changes. As plaintiffs' expert Vail testified, severe overcrowding and understaffing make it difficult for correctional officers to notice behavioral changes. It is simply unrealistic to rely on ADOC's overburdened correctional officers to identify and refer prisoners who may need mental-health treatment, except perhaps for those prisoners with the most obvious symptoms of mental illness.

         In addition to delaying treatment or leaving mental-health symptoms untreated, ADOC's broken referral process has contributed to the phenomenon of prisoners engaging in self-harm or other destructive behavior in order to get attention of mental-health staff. Experts described examples of “increasingly desperate acts” to get the attention of MHM and necessary services, such as self-injury, fire setting, and suicide attempts. Joint Ex. 460, Burns Expert Report (doc. no. 1038-1044) at 29; Haney Testimony at vol. 1, 72 (describing frequent fires in segregation units as desperate attempts to get attention for their needs, including mental-health needs). The court also heard from class member J.A., who has repeatedly engaged in self-harm and expressed suicidal ideation. After summarizing his various attempts to obtain mental-health services while in segregation, including starting fires, J.A. observed, “[G]etting help in prison is harder than getting out of prison.” J.A. Testimony at ___. These are snapshots of unnecessary pain and suffering that could be avoided or at least minimized if prisoner requests for mental-health services were being addressed on a timely basis.

         c. Inadequate Classification of Mental-Health Needs

         ADOC also fails to classify the severity of mental illnesses accurately. The mental-health coding system is intended to reflect the level of functioning a mental-health patient has and correspond to his or her treatment needs and housing requirements. Through multiple revisions, the coding system now includes 13 different codes, ranging from MH-0 to MH-9, with sub-codes for some levels, such as MH-2d. In broad strokes, a higher numbered MH code reflects more intensive care needs: MH-0 refers to no mental-health care need; MH-1 and MH-2 refer to mild impairment or stable enough to receive only outpatient care; MH-3 through MH-5 refer to those who need inpatient care, in either the residential treatment unit (RTU) or intensive stabilization unit (SU); MH-6 refers to those who need to be hospitalized. See Joint Ex. 105, Admin. Reg. § 613 (doc. no. 1038-127).[30]

         Testimony from multiple witnesses and experts made clear that ADOC's mental-health coding system often fails to accurately reflect prisoners' mental-health needs.[31]For example, plaintiff R.M. has been coded MH-2 and housed in general population for most of his incarceration since 1994, despite his severe paranoid schizophrenia and resulting delusions. He was eventually given a higher code and transferred to the Bullock RTU, but Dr. Burns testified that he may need an even higher level of care, and that he suffered from inadequate care while housed for years in an outpatient facility. Likewise, a prisoner identified as #12 in Dr. Burns's report was clearly delusional and believed that televisions and radios were speaking to him; he was in an outpatient facility at the time of his interview with Dr. Burns, but needed to be in a long-term, inpatient facility due to the severity of his schizophrenic symptoms. An email from Associate Commissioner Naglich to Dr. Hunter in December 2015 discussed a schizophrenic prisoner who was clearly delusional and eventually killed another prisoner and threatened to kill a correctional officer; he had been coded as MH-1, which is intended to denote someone who is stabilized with a ‘mild' impairment. Lastly, Dr. Haney gave examples of patients who have been ...


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