Dunn et al v. Thomas et al

Filing 2822

PHASE 2A INPATIENT TREATMENT REMEDIAL OPINION AND ORDER: Therefore, with regard to inpatient mental-health treatment and as discussed and outlined above, it is ORDERED that, on or before 5:00 p.m. on July 1, 2020, the defendants, with input from t heir experts, are to submit the following to the court: (1) a plan to ensure the creation of more and adequate inpatient treatment beds; (2) a plan to ensure the creation of more and adequate treatment space; (3) a plan to make all SU cells suicide-resistant; and (4) a plan to manage high temperatures for patients on psychotropic medication, as further set out in order. Signed by Honorable Judge Myron H. Thompson on 5/29/2020. (kh, )

IN THE DISTRICT COURT OF THE UNITED STATES FOR THE
MIDDLE DISTRICT OF ALABAMA, NORTHERN DIVISION
EDWARD BRAGGS, et al.,
Plaintiffs,
v.
JEFFERSON S. DUNN, in his
official capacity as
Commissioner of
the Alabama Department of
Corrections, et al.,
Defendants.

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CIVIL ACTION NO.
2:14cv601-MHT
(WO)

PHASE 2A INPATIENT TREATMENT
REMEDIAL OPINION AND ORDER
Previously this court found that the State of Alabama
provides inadequate mental-health care in its prisons in
violation of the Eighth Amendment’s prohibition against
cruel and unusual punishment.

See Braggs v. Dunn, 257

F. Supp. 3d 1171, 1267 (M.D. Ala. 2017) (Thompson, J.).
The issue now before the court is whether the defendants’
plan

to

remedy

treatment--that
Residential

the

deficiencies

is,

mental-health

Treatment

Units

found

(RTUs)

in

treatment
and

inpatient
in

the

Stabilization

Units (SUs)--is adequate.1
proposed

plan

fails

to

The court finds that their
ensure

minimally

adequate

inpatient care in four of nine key disputed areas:

(1)

ensuring

(2)

an

adequate

number

of

treatment

beds;

ensuring adequate treatment space; (3) making SU cells
suicide-resistant; and (4) managing high temperatures for
patients on psychotropic medication.

Accordingly, the

court will order the relief necessary to address these
deficiencies

and

remedy

the

constitutional

violation

found.

I.

BACKGROUND

A. Procedural Background
The plaintiffs in this class-action lawsuit include
inmates with mental illness in the custody of the Alabama

1. The court and the parties have sometimes referred
to the RTUs and SUs collectively as ‘residential
treatment units.’
To avoid confusion, the court will
instead use the terms ‘inpatient care units’ or
‘mental-health units’ to refer to RTUs and SUs
collectively. Meanwhile, the court will refer to care
provided in hospital-level settings exclusively as
‘hospital-level care.’
2

Department of Corrections (ADOC).

The defendants are the

ADOC Commissioner and the ADOC Associate Commissioner of
Health Services, who are both sued in only their official
capacities.

In a liability opinion, this court found

that ADOC’s mental-health care was, “[s]imply put, ...
horrendously inadequate.”

Braggs, 257 F. Supp. 3d at

1267.
After

two

months

of

mediation

to

develop

a

comprehensive remedial plan to address all of the factors
contributing to the Eighth Amendment violation, it became
apparent that the remedy was too large and complex to be
addressed all at once.

The court therefore severed the

remedy into several discrete issues, to be addressed
seriatim.

See Phase 2A Revised Remedy Scheduling Order

on Eighth Amendment Claim (doc. no. 1357).
issues,

which

simultaneous

the

court

resolution,

later
are

Two related

consolidated

for

“identification

and

classification of prisoners with serious mental-health
needs” and “out-of-cell time and treatment for inmates
in need of residential treatment,” that is, inpatient

3

care.

See Additional Phase 2A Revised Remedy Scheduling

Order on Eighth Amendment Claim (doc. no. 1524) at 2.
In the liability opinion, the court found that ADOC
“fails to provide residential-level care to those who
need it,” as a result of flawed identification processes.
Braggs, 257 F. Supp. 3d at 1205.

Specifically, the court

found ADOC’s historically inadequate intake and referral
processes led to empty beds in RTUs and SUs, despite the
existence of individuals in need of inpatient care.
id.

See

Those who do make it into the inpatient units, the

court found, still fail to receive proper care.
at 1212.

See id

Instead, the inpatient units operate “almost

exactly the same way” as segregation, id., with “a severe
lack of out-of-cell time[] and a lack of meaningful
treatment activities,” id. at 1214.

These conditions put

patients “at a substantial risk of continued pain and
suffering,

decompensation,

and

self-harm.”

Id.

In

short, “ADOC's failure to provide adequate treatment and
out-of-cell time in mental-health units forces the most
severely mentally ill patients to face yet another risk

4

factor for decompensation, even though their placement
was for the specific purpose of alleviating the symptoms
of their mental illness.”

Id. at 1217.

When the court turned to the remedy for these two
related elements of the Eighth Amendment violation, it
gave the defendants an opportunity to propose a remedial
plan

and

allowed

Defendants’

Phase

Identification,
Out-of-Cell

the

plaintiffs

2A

Proposed

Classification,

Time

and

to

respond.

Remedial
and

Treatment

Plan

Residential

(doc.

Plaintiffs’ Response (doc. no. 1649).

See

no.

on
Unit

1594);

The parties then

reached agreements, which the court approved, regarding
remedies

for

the

first

issue--ADOC’s

deficient

classification and identification processes, including
both intake and referral.

See Coding Injunction (doc.

no. 1792); Intake Injunction (doc. no. 1794); Referral
Injunction (doc. no. 1821).
The court later held a hearing on the issues not
resolved

by

the

parties’

agreements

and

whether

any

remedial order at all should be entered as to inpatient

5

treatment at this time.
have

reached

Since the hearing, the parties

additional

stipulations

regarding

out-of-cell time and treatment in inpatient units:

the

Individualized Treatment Planning Injunction (doc. no.
1865); the Psychotherapy and Confidentiality Injunction
(doc.

no.

1899);

Confidentiality

and

the

Injunction

(doc.

Correctional
no.

Officer

1900).

These

stipulations include that ADOC must provide 10 hours of
structured and 10 hours of unstructured out-of-cell time
per week in all inpatient units.

See Psychotherapy and

Confidentiality Stipulations (doc. no. 1899-1).

The

parties also agreed that the units shall have available
at least psycho-educational groups, individual therapy,
group

psychotherapy,

therapy.

pharmacotherapy,

and

activity

See id at 2.

In March 2020, the court issued an interim injunction
to enforce all of the parties’ stipulations until, at the
latest, December 30, 2020.
no. 2793).
the

issue

See Interim Injunction (doc.

Because of the novel coronavirus pandemic,
of

whether

the

6

stipulations

satisfy

the

requirements of the Prison Litigation Reform Act (PLRA),
18 U.S.C. § 3626(a)(1)(A), beyond that date cannot be set
for final resolution until the fall, and the court will
defer judgment as to whether the measures are warranted
until that hearing has occurred.

Regardless, the court

relies in this opinion on the defendants’ representations
that they agreed to the stipulations in good faith and
that ADOC intends to continue complying with them.

See

Mar. 5, 2019, Status Conf. Tr. (doc. no. 2399) at 42 (the
defendants stating that “the Department of Corrections
negotiated these stipulations in good faith.

And we're

still focused on compliance with those orders”).
stipulations

affecting

today’s

order

on

The

inpatient

treatment units are described in detail throughout this
opinion.

B. Factual Background
As stated, ADOC’s inpatient care includes two types
of units, RTUs and SUs, which together house and treat
the

most

severely

mentally

7

ill

inmates.

RTUs

are

intended to provide a therapeutic environment to mentally
ill inmates in need of intensive and ongoing care.

There

are three levels to the RTU: inmates in levels one and
two (called ‘closed’ RTUs) live in individual cells while
level three is ‘open,’ which means that patients live in
an open dormitory with other RTU residents.

RTU levels

are decreasingly intensive and restrictive from level one
to level three, with some patients progressing through
the

levels

as

their

conditions

improve

and

others

remaining at a particular level based on their ongoing
conditions and symptoms.
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 who
have not been stabilized through other interventions.
SUs

are

the

most

intensive

and

restrictive

units,

intended to stabilize patients as quickly as possible so
that they can return to a less-restrictive environment.
All SU patients are housed in an individual cell.

8

Three of ADOC’s major prison facilities--Bullock,
Donaldson, and Tutwiler--serve as ‘treatment hubs’ for
mental-health services and contain RTUs and SUs.

In

addition to these treatment hubs, Kilby has a limited
number of SU beds.

II. LEGAL STANDARD
The court’s remedial order regarding the SUs and RTUs
is governed by the PLRA, which provides that a “court
shall not grant or approve any prospective relief unless
the court finds that such relief is narrowly drawn,
extends
violation

no
of

further
the

than

necessary

Federal

right,

to

and

correct
is

the

the
least

intrusive means necessary to correct the violation of the
Federal

right.”

18

U.S.C.

§ 3626(a)(1)(A).

In

conducting this ‘need-narrowness-intrusiveness’ inquiry,
the court is required to “give substantial weight to any

9

adverse impact on public safety or the operation of a
criminal justice system caused by the relief.”

Id.

“As this court has stated before, [prison officials
in cases challenging prison conditions] should be given
considerable

deference

remedy

for

the

Laube

v.

Haley,

in

determining

constitutional
242

F.

an

violations

Supp.

2d

appropriate
involved.”
1150,

1153

(M.D. Ala. 2003) (Thompson, J.) (citing Bell v. Wolfish,
441 U.S. 520, 547-48 (1979)); see also Turner v. Safley,
482 U.S. 78, 85 (1987) (“[F]ederal courts have ... reason
to

accord

deference

to

the

appropriate

prison

authorities.”).
Nevertheless, this court retains the responsibility
to remedy a constitutional violation.
Plata, 563 U.S. 493, 511 (2011).
sensitive

to

the

State’s

See Brown v.

While a court “must be

interest

in

punishment,

deterrence, and rehabilitation, as well as the need for
deference to experienced and expert prison administrators
faced with the difficult and dangerous task of housing
large numbers of convicted criminals,” id., it “must not

10

shrink

from

[its]

constitutional
prisoners.”
omitted).
to

obligation

rights

Id.

of

all

to

enforce

persons,

the

including

(internal quotation marks and citations

It “may not allow constitutional violations

continue

simply

because

a

remedy

would

involve

intrusion into the realm of prison administration.”
Accordingly,

the

deference

afforded

Id.

prison

administrators in remedying a constitutional violation
must not be “complete.”

King v. McCarty, 781 F.3d 889,

897 (7th Cir. 2015) (per curiam) (citing Plata, 563 U.S.
at 511).

III. DISCUSSION
Though the parties have agreed to many remedial
measures to address the constitutional inadequacies in
ADOC’s

inpatient

mental-health

issues remain in dispute.

treatment,

significant

The plaintiffs ask the court

to order relief in nine areas: (1) increasing the number
of inpatient treatment beds available; (2) increasing the
amount of confidential treatment space; (3) making all

11

SU cells suicide-resistant; (4) air conditioning all
mental-health

units;

(5)

establishing

admissions

criteria for the different levels of inpatient treatment;
(6) defining privileges and rights of patients in the
units; (7) increasing natural light; (8) and providing
additional training to correctional officers who work in
mental-health units.

The plaintiffs also seek a court

order regarding (9) monitoring of inpatient treatment.
The defendants, on the other hand, argue that the
court should not enter any remedial order at this time.
First, they contend that the remedy is limited in scope
to out-of-cell time and treatment and that the remedial
orders the plaintiffs seek do not fit into either issue.
Second, they argue that criticisms of their proposed
remedial plan are premature and that the court should
give the defendants an opportunity to implement their
plan before entering any remedial order.
For the reasons that follow, the court finds the
defendants’ proposed plan incomplete with regard to the
first four of the nine areas listed above.

12

A. Number of Inpatient Treatment Beds
i. Findings
In the liability opinion, the court found that “ADOC
does not adequately utilize residential treatment unit
beds and fails to provide residential-level care to those
who

need

symptoms.”
this

it,

leading

persistent

or

Braggs, 257 F. Supp. 3d at 1205.

conclusion,

Dr. Raymond

to

the

court

Patterson’s

credited

opinion

worsening
In reaching

defense

that,

expert

based

on

comparisons to other American prison systems, “roughly
15 % of prisoners on [ADOC’s] mental-health caseload
should be housed in RTU or intensive stabilization unit
settings.”

See

id.

With

3,439

patients

on

the

mental-health caseload in September 2016, see Joint Ex.
344, Sept. 2016 Monthly Operating Report (doc. no. 1038703) at 1, Dr. Patterson’s 15 % estimate meant that
“approximately 515 ADOC prisoners should [have been]
housed in the RTU or the SU,” Braggs, 257 F. Supp. 3d at
1205.

However, only “310 of the 376 RTU and SU beds were

13

being used to house prisoners with mental-health needs.”
Id.

Internal reports from ADOC showed that “[t]his

practice of not filling even existing mental-health unit
beds has persisted for years.”

Id.

Since the liability opinion, the estimate that 15 %
of

the

mental-health

caseload

requires

inpatient

treatment has emerged as an expert consensus.

In her

testimony about the defendants’ proposed remedial plan,
plaintiff expert Dr. Kathryn Burns agreed with defense
expert Dr. Patterson that “ADOC should have residential
treatment beds of one sort or another for 15 % of the
[mental-health] caseload.”
(doc. no. 2696) at 114.

Apr. 27, 2018, Trial Tr.
Defense consultant Dr. Mary

Perrien also agreed with the 15 % estimate.

See Dec. 12,

2017, Trial Tr. Rough Draft (R.D.) at 85 (“Q: ... as a
general matter, you anticipate that 15 % of the caseload
would be housed in the RTU or SU; correct?
correct.”).
the

overall

A: That’s

Dr. Perrien suggested, however, that 1 % of
caseload

should

receive

either

SU

or

hospital-level care, and thus, the 15 % estimate may

14

include

those

requiring

hospital-level

settings

in

addition to those who should be housed in the RTUs and
SUs.

See id. at 87.
The court also found that ADOC, at the same time,

systematically under-identifies mentally ill inmates and
that,

therefore,

the

mental-health

caseload

was

significantly smaller than would be expected under a
functioning intake, classification, and referral system.
See Braggs, 257 F. Supp. 3d at 1205 n.32.
2016,

the

caseload

approximately

14

in
%

major
for

ADOC
men

In September

facilities
and

52 %

was
for

women--substantially less than the 20 to 30 % average
rate of mental illness for men and 75 to 80 % average for
women in correctional systems across the country.2

See

2. In the liability opinion, the court relied on the
actual ADOC caseload percentages of between 14 % and 15 %
for men and 54 % for women at Tutwiler Prison for Women,
which came from ADOC statistics from June 2016. See
Braggs, 257 F. Supp. 3d at 1201, 1248. However, because
the court ultimately relied on the mental-health caseload
from the September 2016 monthly report to calculate the
estimated need for 515 inpatient beds, the court instead
uses the September 2016 mental-health caseload statistics
here. In September 2016, the male population in ADOC
major facilities was 18,711 with a caseload of 2,696 and
15

id. at 1201.

Thus, the court’s estimate of 515 inmates

in need of inpatient treatment, based on 15 % of the
caseload at that time, likely was significantly less than
the reality of the existing need.

See id. at 1205 n.32.

ii. Changes to Identification Procedures
As discussed, the parties have since entered into
stipulations to address the issue of under-identification
of

inmates

with

mental-health

needs.

See

Intake

Injunction (doc. no. 1794); Referral Injunction (doc. no.
1821).

These stipulations, which are aimed at improving

the intake and referral processes, and their effects on
the mental-health caseload are described below.

a. Intake
ADOC’s failure to utilize adequately its inpatient
treatment

units

is

“a

problem

that

inadequate intake screening process.”

starts

with

the

Braggs, 257 F.

the female population at Tutwiler was 885 with a caseload
of 458. See Joint Ex. 344, Sept. 2016 Monthly Operating
Report (doc. no. 1038-703) at 1.
16

Supp. 3d. at 1206.
that

Experts from both sides testified

fundamentally

flawed

intake

procedures

led

to

systematic under-identification of mentally ill inmates,
including those in need of inpatient treatment.

See id.

At the time of the liability trial, the intake process
was

conducted

by

unsupervised

licensed

nurse

practitioners (LPNs) who are unqualified “to assess the
presence or acuity of mental illness symptoms based on
the information obtained during the intake process.”
at 1202.
some

Further, the problem of understaffing led to

inmates

process;

Id.

not

without

even
enough

participating

in

mental-health

this

intake

practitioners,

inmates were sometimes sent from Kilby, where all male
inmates are screened, to other facilities without having
received an initial intake.
To
parties

remedy
reached

the

See id at 1203.

inadequate

stipulations

intake

procedures,

requiring

the

the

following

steps, among others, be taken upon an inmate’s arrival
to ADOC.

See Intake Injunction (doc. no. 1794).

As soon

as possible and no later than 12 hours after arrival, a

17

registered nurse (RN) with mental-health training must
conduct and document a mental-health intake screening.
See Intake Stipulations (doc. no. 1794-1) at 1.

Using

agreed-upon intake tools and metrics, the mental-health
RN will determine whether a referral is indicated and,
if so, designate whether it is emergent, urgent, or
routine, as defined by the parties’ agreement.
at 5.

See id.

Where a referral has been made to psychiatry, a

psychiatrist will evaluate the inmate within seven days
of

a

nonurgent

referral.
For

and

24

hours

14

days

of

an

urgent

the

intake

See id. at 10-11.

every

screening,

referral

a

inmate,

within

psychologist

or

licensed

of

mental-health

professional will conduct an additional mental-health
screening

including

a

social-history

suicide-risk assessment.
psychologist,
nurse

psychiatrist

See id. at 7-8.

psychiatrist,

practitioner
will

(CRNP)
then

assessment

or

certified

collaborating

assign

the

and

A licensed
registered
with

a

individual

a

mental-health code after review of the intake screening

18

and assessment results.

See id. at 8.

The mental-health

code assigned to each inmate shall be considered and
utilized by ADOC Classification personnel when making
institutional assignments.

See id. at 13.

b. Referral
The parties have also agreed to measures to improve
referral procedures.
1821).

See Referral Injunction (doc. no.

As the second mechanism for identifying and

classifying inmates with mental illness (intake being the
first), the referral process is critical to identifying
“prisoners whose mental illnesses develop during their
incarceration and prisoners whose mental-health needs
were not identified during the intake process.”
257 F. Supp. 3d. at 1203.
experts

from

both

sides

Braggs,

During the liability trial,
agreed

process was seriously deficient.

that

ADOC’s

referral

First, the court found

ADOC lacked “a system to triage and identify the urgency
of each request, and to make referrals according to the
level of urgency.”

Id.

Second, the court found that

19

correctional officers, who were already overburdened due
to overcrowding and understaffing, were ill-positioned
to identify and refer inmates with mental-health needs.
See id. at 1203-04.
The parties have since agreed that all ADOC personnel
who

have

direct

contact

with

inmates,

including

correctional officers, must complete a ‘Comprehensive
Mental Health Training Curriculum,’ to be approved by
plaintiff expert Dr. Burns.
(doc. no. 1821-1) at 1-2.

See Referral Stipulations
This comprehensive training

will include curricula regarding “[t]he early warning
signs or symptoms of mental illness”; “[t]he availability
of mental health services within the ADOC”; “[t]he nature
and extent of mental health services available within the
ADOC”; “[t]he process for referring inmates for mental
health evaluations,” id. at 3; and “how to properly
characterize what is an emergent, urgent, or routine
referral,” Additional Stipulations Regarding Referrals
(doc. no. 1821-2) at 7.

The parties represented at a

hearing in December 2019 that development and approval

20

of this training were still in process but would soon be
complete.

See Dec. 6, 2019, Status Conf. Tr. (doc. no.

2686) at 62.

Upon approval of this training, all staff

to receive the training must do so within 30 days of
assignment

to

a

major

facility.

See

Additional

Stipulations Regarding Referrals (doc. no. 1821-2) at 7.
The

parties

have

also

clarified

that

inmates

themselves may request mental-health services and that
“[a]ny

individual

working

within

ADOC

may

refer

any

inmate within a major facility for assessment by mental
health personnel.”

Id. at 1.

The stipulations describe

the referral procedures and documentation required for
emergent, urgent, and routine referrals.

All referrals

must result in a clinical assessment and/or intervention
by a mental-health provider, psychologist, mental-health
CRNP, or psychiatrist.
no. 1821-1) at 5.

See Referral Stipulations (doc.

To triage these requests, ADOC has

committed to designating one nurse per shift to serve as
the triage nurse at every major facility, who must be at
least qualified as an RN with mental-health training.

21

See Additional Stipulations Regarding Referrals (doc. no.
1821-2) at 2-3.

c. Effects of Stipulations
The

stipulations

regarding

intake

and

referral

processes appear to target the deficiencies the court
found

to

contribute

to

the

under-identification

of

inmates with mental-health needs, including those in need
of inpatient treatment.

According to plaintiff expert

Dr. Burns and ADOC Director of Psychiatry Dr. Edward
Kern, once ADOC has functioning identification processes,
it

should

expect

its

mental-health

caseload

to

substantially increase to reflect the average caseload
in American prisons with functioning mental-health care
systems.

See Apr. 27, 2018, Trial Tr. (doc. no. 1817)

at 16 (Dr. Burns’s testimony that functioning intake will
increase the mental-health caseload); Apr. 25, 2018,
Trial Tr. (doc. no. 1942) at 46 (Dr. Kern’s testimony
that the mental-health caseload is expected to increase
under functioning intake and classification system).

22

At

the December 2019 hearing, counsel for the plaintiffs
represented that, as a result of updated identification
procedures,

the

mental-health

caseload

is

now

approaching, but not yet reaching the size the experts
expect.
30.

See Dec. 6, 2019, Hr’g Tr. (doc. no. 2686) at

According to a report filed shortly after that

hearing, the caseload has reached 21 % of the total male
ADOC population (up from 14 %) and 67 % of the female
population (up from 52 %).

See Joint Report Regarding

the Mental Health Caseload (doc.

no. 2705) (showing a

male caseload of 3,543 and a female caseload of 608);
Dec. 2019 ADOC Monthly Statistical Report at 4, available
at
http://www.doc.state.al.us/docs/MonthlyRpts/DMR%2012%20
December%202019PUB.pdf (showing a male population in ADOC
major facilities of 16,585 and a female population at
Tutwiler of 901).
representation
caseload

is

The plaintiffs made the unrefuted

during
expected

the

December

to

hearing

continue

that

expanding

the
and

stabilizing until it reaches a representative proportion

23

of the ADOC population around October 2020.

See Dec. 6,

2019, Hr’g Tr. (doc. no. 2686) at 30.
To be sure, the number of patients in RTUs and SUs
has also increased since the liability trial.

As of

December 2019, ADOC is housing 387 men and 18 women in
inpatient units, see Joint Report Regarding the Mental
Health Caseload (doc.

no. 2705),3 up from the 310 men

and 14 women housed in these units in 2016, see Joint Ex.
344,

Sept.

2016

1038-703) at 3-4.
marginal

increase

mental-health

Monthly

Operating

Report

(doc.

no.

However, these numbers reflect only a
in

the

caseload

overall

percentage

housed

in

of

the

mental-health

units--from 9.4 % in September 2016, see id., to 9.8 % in

3. Importantly, the December filing reports “the
total number of inmates receiving residential-level
mental health treatment in ADOC’s residential treatment
units and stabilization units,” not necessarily all those
actually in need of inpatient care. Joint Report
Regarding the Mental Health Caseload (doc. no. 2705) at
1 n.1 (emphasis added).
24

December 2019, see Joint Report Regarding the Mental
Health Caseload (doc. no. 2705).

4

iii. Remaining Areas of Dispute
The defendants argue that the liability opinion does
not mandate any remedial action regarding the number of
inpatient treatment beds available.

According to the

defendants’ plan, there are 46 SU beds and 400 RTU beds
available across all facilities for men, and eight SU
beds and 50 RTU beds available for women. See Defendants’
Phase

2A

Proposed

Remedial

Plan

on

Identification,

Classification, and Residential Unit Out-of-Cell Time and
Treatment (doc. no. 1594) at 24, 26.

The defendants

argue that the 96 beds in the Structured Living Unit

4. The court reaches these calculations by dividing
the total number of patients in RTUs and SUs by the
mental-health caseload size.
In September 2016, there
were 324 total patients in RTUs and SUs and 3,439 patients
reported on the caseload. See Joint Ex. 344, Sept. 2016
Monthly Operating Report (doc. no. 1038-703) at 1, 3-4.
In December 2019, there were 405 patients in RTUs and SUs
and 4,151 patients on the caseload.
See Joint Report
Regarding the Mental Health Caseload (doc. no. 2705) at
1.
25

(SLU) at Donaldson should also be included in the total
number of beds in the “mental-health units.”

Defendants’

Reply in Support of Proposed Opinion (doc. no. 1849) at
7 n.5.

The SLU is “a diversionary outpatient unit for

persons with serious mental illness or who are otherwise
found

to

be

inappropriate

for

a

restrictive

housing

placement in lieu of a restrictive housing placement.”
Psychotherapy and Confidentiality Stipulations (doc. no.
1899-1) at 13.
ADOC
inpatient

does

not

treatment

plan

to

beds

increase

the

available.

number

Rather,

of
the

defendants assert that the existing beds are sufficient
to meet the need, demonstrated by the number of beds
unused and available in the RTUs and SUs.

They further

assert that the projected number of inmates in need of
inpatient treatment at ADOC prisons is speculative given
the possibilities that ADOC will house fewer inmates
overall;

that

some

patients

will

be

transferred

to

hospital-level care; and that, with improvements to other
inadequacies in the provision of mental-health care,

26

fewer

inmates

will

need

inpatient

treatment.

See

Defendants’ Reply in Support of Proposed Opinion (doc.
no. 1849) at 19-21; June 18, 2018, Oral Arg. Tr. (doc.
no. 1905) at 45-46.
The plaintiffs initially argued that, based on the
most conservative calculation of the need for inpatient
treatment,

the

court

should

order

the

defendants

to

“construct, refurbish, or otherwise establish a total of
500 mental-health unit beds for prisoners at men’s major
facilities and 128 mental-health unit beds for prisoners
at

women’s

Opinion

major

(doc.

no

facilities.”
1840)

at

Plaintiffs’

18.

More

Proposed

recently,

the

plaintiffs instead requested that the court order ADOC
to “reassess the need for RTU/SU beds once its caseload
stabilizes.”

Joint Report Regarding the Mental Health

Caseload (doc. no. 2705) at 3.
The

plaintiffs

argue

that

ADOC’s

continued

underutilization of its existing beds is not evidence
that more beds will not be needed, but rather that ADOC
still fails to identify individuals in need of inpatient

27

treatment.

The plaintiffs assert that the agreed-upon

remedial measures to address under-identification will
continue

to

increase

the

number

of

patients

on

the

caseload as well as increase the number of patients
identified as needing inpatient care.

They also point

to defense expert Dr. Patterson’s opinion that vacancies
in mental-health units were likely partly due to the lack
of treatment provided, which rendered placement in those
units minimally useful.
(doc. no. 1277) at 286.

See Jan. 31, 2017, Trial Tr.
The plaintiffs assert that, when

the mental-health units are functioning--that is to say,
providing treatment and out-of-cell time and meeting
their therapeutic purpose--ADOC will see an increase in
the number of inmates referred to and retained in RTUs
to receive the level of care they need.

iv. The Court’s Resolution
The court finds that the defendants’ plan fails to
account for the number of inpatient treatment beds that
will be required once ADOC properly identifies and refers

28

inmates

for

necessary

inpatient

treatment.

For

the

reasons that follow, the court finds that doing nothing
to ensure that ADOC has enough beds to meet the need is
unacceptable.

However, the court does not think it is

appropriate, at this time, to require the defendants to
create a specific number of beds.

Instead, the court

will take the more limited approach of ordering them to
devise their own plan as to how they will accommodate the
increasing need.
The defendants’ ‘do nothing’ approach to the issue
of bed space is inadequate for several reasons.

First,

basing a remedial plan on the ‘actual’ caseload and
current

identified

need

for

inpatient

treatment

encourages ADOC to continue to under-identify the need
and

underutilize

its

creating more beds.

mental-health

units

to

avoid

The court has already found these

practices contribute to decompensation, self-harm, and
pain, in violation of the Eighth Amendment.
Second, the need for additional inpatient treatment
beds

is

not

merely

“hypothetical”

29

as

the

defendants

argue.
(doc.

Defendants’ Reply in Support of Proposed Opinion
no.

1849)

at

18.

ADOC’s

present

caseload

statistics do not change the experts’ agreement that the
size

and

needs

of

the

caseload

should

approximate

averages from correctional systems across the country.
As discussed, the experts agree that ADOC can anticipate
approximately 15 % of the mental-health caseload to need
inpatient mental-health treatment.
findings,

the

court

found

no

In its liability

reason

to

expect

a

substantial deviation from national averages in ADOC
prisons. Braggs, 257 F. Supp. 3d at 1201. The defendants
have not presented any evidence to suggest the experts’
projections are an overestimate.5
Based on the experts’ projections, the need for
inpatient

treatment

is

due

to

outgrow

the

existing

5. The court is not persuaded by the defendants’
argument that the need for inpatient treatment will not
increase because outpatient treatment will improve. The
experts’ estimate of 15 % is based on comparisons to
other prison systems in the United States that presumably
provide at least minimally adequate outpatient mentalhealth treatment.
Once ADOC’s outpatient treatment
improves and its identification processes are fully
30

inpatient

treatment

units.

As

ADOC

continues

to

implement the agreed-upon remedial measures, the size of
the

mental-health

caseload

has

increased

and

should

continue to increase, as should the number of patients
referred for inpatient treatment.

For men, the caseload

has already grown from 14 % to 21 % of the population,
slightly exceeding the experts’ conservative estimate of
20 %.

See Dec. 2019 ADOC Monthly Statistical Report at

4,

available

at

http://www.doc.state.al.us/docs/MonthlyRpts/DMR%2012%20
December%202019PUB.pdf. Calculating 15 % of the December
male caseload results in an estimate of 531 beds required
to

meet

the

need

for

residential-level

care--substantially more than the 446 beds ADOC reports
are currently available.
not

yet

reached

the

Though the female caseload had
conservative

estimate,

as

of

December, it had also grown from 52 % to 67 % of the
population.

Id.

The December female prison population

functioning, the percentage of inmates identified for
inpatient treatment should increase.
31

of

901,

id.,

yields

a

conservative

projection

of

a

caseload of 676 patients, such that approximately 101
female inmates should be housed in inpatient care units.
Even

applying

the

under-representative

15 %

estimate

December

2019

to

female

the

caseload,

ADOC’s existing 58 inpatient beds fall short of the
approximately

91

female

inpatient treatment.

inmates

projected

to

need

These numbers mean that there are

currently enough beds for only 12.6 % of the December
male

caseload

and

only

under-representative

9.5

%

of

even

December

the

female

caseload--substantially less than 15 %.
Meanwhile, despite the fact that the projected needs
significantly exceed the existing capacities of the RTUs
and

SUs,

many

inpatient

beds

remain

vacant.

The

defendants reported in December that only 387 men and,
perhaps most concerningly, only 18 women were receiving
inpatient care.

These vacancies do not support a finding

that

enough

ADOC

has

treatment

beds.

Rather,

they

reflect the substantial likelihood that approximately 144

32

men and 83 women are still not receiving the inpatient
treatment they need.

More than three years after the

liability trial, it appears that ADOC continues both to
under-identify mental-health needs and underutilize its
existing inpatient beds.

This ongoing failure may be

explained in part by the fact that, though the intake and
referral stipulations have been in place for over two
years now, their full implementation has been delayed.
First,

as

regarding

of
the

December
caseload

2019,

when

the

statistics

joint

was

report

filed,

the

‘Comprehensive Mental Health Training,’ which includes
training for correctional staff on identifying mental
illness symptoms and making mental-health referrals, had
not yet been finalized and implemented.
significantly,

understaffing

is

an

Second, and most

ongoing

obstacle.

Without sufficient mental-health and correctional staff
to implement the intake and referral processes, remedial
measures can go only so far to address the problem of
under-identification. Thus, though ADOC may have updated
its

policies

and

procedures

33

and

seen

some

resulting

improvements, the court finds that the status of the
mental-health caseload and inpatient units does not yet
reflect

the

results

expected

once

ADOC

has

fully

implemented the identification and staffing remedies.
Nonetheless, in deference to the defendants, the
court declines to order the creation of a specific number
of additional RTU or SU beds to meet the expected need.
Instead, the court will order the defendants to propose
a plan for how it will accommodate the expected increase
in patients referred for inpatient treatment, based on
the

experts’

approximately
caseload.6

projection
15 %

of

that
the

this

number

projected

will

be

mental-health

Alternatively, if the defendants contest the

experts’ consensus, they may conduct a “needs assessment”
of ADOC’s specific system, as posed by defense expert
Dr. Patterson as another way to estimate the need.
31, 2017, Trial Tr. (doc. no. 1277) at 90-91.
assessment

will

be

subject

to

the

Jan.

Any such

court’s

later

6.
The defendants’ plan should take into account
that, as of December, the male caseload already exceeded
the experts’ conservative projection.
34

determination of the reliability of the assessment’s
findings.
a

plan

The court will allow the defendants to propose
based

either

on

the

expert

consensus

or,

alternatively, based on the results of an independent
needs assessment.
In any case, the defendants may not include in their
calculation of existing beds the beds in the Structured
Living Unit (SLU), which is an outpatient unit created
since the start of this litigation as an alternative to
segregation for inmates with serious mental illness.

See

Psychotherapy and Confidentiality Stipulations (doc. no.
1899-1) at 13.

The parties have already agreed that

inmates “in need of residential-level care shall not be
housed in the SLU.”
The

court

Id.

does,

however,

accept

the

defendants’

assertion that adequate provision of hospital-level care
may narrow the gap between the need for and the existing
number

of

SU

beds.

ADOC

has

contracted

for

14

hospital-level treatment beds at Citizens Baptist Medical
Center.

See Joint Report Regarding the Mental Health

35

Caseload (doc. no. 2705) at 2.

In accordance with the

parties’ stipulations on hospital-level care, ADOC has
also agreed to reassess ADOC’s need for hospital beds on
an annual basis.

See Amended Stipulation Regarding the

Provision of Hospital-Level Care (doc. no. 2383-1) at 2.
As discussed, defense consultant Dr. Perrien indicated
that, when calculating the 15 % of the caseload in need
of inpatient treatment she would include inmates in need
of hospital-level care, in addition to those housed in
RTUs and SUs.

See Dec. 12, 2017, Trial Tr. R.D. at 87.

Accordingly, the defendants may include in their plan an
explanation of how, if at all, these 14 hospital beds
affect the number of SU beds needed.
Finally, the defendants’ proposed plan should also
take into consideration their own expert Dr. Patterson’s
caution not to simply “throw” more beds into the existing
RTUs and SUs: “[I]t trivializes if we just put more beds
in, we’ll be okay. ... The environment has to be safe.
Don’t put our officers at risk of being harmed. ...
[T]hat’s why I’m hesitant to suggest just throwing beds

36

at it will fix it.

There’s much more to it than that.”

See Jan. 31, 2017, Trial Tr. (doc. no. 1277) at 252-53.

v. PLRA Findings
Section 3626(a)(1)(A) of the PLRA requires a district
court to make particularized findings that each provision
of

prospective

relief

ordered

narrowness-intrusiveness’

satisfies

‘need-

See

requirement.

the

United

States v. Sec’y, Fla. Dep’t of Corr., 778 F.3d 1223, 1228
(11th

Cir.

2015).

The

court

now

finds

that

the

requirement that the defendants plan for how they will
accommodate all those referred for inpatient treatment
under

ADOC’s

improved

satisfies the PLRA.

identification

procedures

While the defendants take issue with

the contention that ADOC requires more inpatient beds,
the court’s remedial order is based on the consensus of
the witnesses, including the defendants’ own expert and
consultant.

Ensuring sufficient treatment beds to meet

the needs of ADOC’s seriously mentally ill population is
foundational

to

remedying

37

this

element

of

the

constitutional violation: that ADOC fails to provide
minimally adequate inpatient mental-health treatment to
those who need it.

Without enough RTU and SU beds,

inmates in need of inpatient treatment will necessarily
continue to be housed in units that do not provide them
with the level of treatment they need.
the

liability

opinion,

“these

As described in

practices

also

have

a

downward-spiral effect on the rest of the system: those
who do not get needed treatment often end up in crisis
cells, frequently receive disciplinary sanctions, and may
be placed in segregation, where they have even less
access to treatment and monitoring.”
Supp. 3d at 1206.

Braggs, 257 F.

Until ADOC creates and implements a

plan to address this need, it will continue to put inmates
with mental illness at a substantial risk of serious
harm.
The

court

finds

that

the

requirement

that

the

defendants devise a plan to meet the need for inpatient
beds is narrowly drawn, extends no further than necessary

38

to remedy the constitutional violation found, and is the
least intrusive means of doing so.

B. Treatment Space
i. Findings
Treatment space is out-of-cell space where patients
housed

in

mental-health

counseling

appointments

activities.

As discussed, the court previously found

that

out-of-cell

required

time

components

units
and

and

of

can

participate

therapeutic

treatment

minimally

group

activities--both

adequate

inpatient

care--were severely lacking in ADOC’s RTUs and SUs.
Braggs, 257 F. Supp. 3d at 1214.

in

See

“Without bringing

patients out of their cells for counselling sessions,
treatment team meetings, group sessions, and activities,
placement in a ‘mental-health unit’ does no good for
patients who need the highest level of care; careful
observation and treatment cannot happen when confined in
a small cell all day.”
court

found

that

10

Id.

In the liability phase, the

hours

39

of

structured

therapeutic

activity and 10 hours of unstructured activity per week
are the standard in mental-health units in prisons around
the country.

See id. at 1215.

Although this standard

“does not necessarily set the constitutional floor, a
substantial deviation from the acceptable professional
standard could support a finding of an Eighth Amendment
violation.”

Id.

(internal citation omitted).

The parties have since agreed that ADOC will follow
this national standard and provide 10 hours of structured
therapeutic out-of-cell time and 10 hours of unstructured
out-of-cell

time

per

week

to

mental-health units by March 2020.7

all

patients

in

See Psychotherapy

and Confidentiality Stipulations (doc. no. 1899-1). ADOC
has also agreed to offer, at a minimum, psychoeducational
groups,

individual

therapy,

group

pharmacotherapy, and activity therapy.

therapy,

See id. at 2.

Per the parties’ agreement, sessions must be held in

7. The court does not have up-to-date information
regarding the status of implementation of this agreement,
but, as stated, assumes that ADOC is complying with all
agreements, per defendants’ representations to the court.
See Mar. 5, 2019, Status Conf. Tr. (doc. no. 2399) at 42.
40

settings

that

provide

for

confidentiality,

with

an

exception only where it “is not possible due to safety
concerns, based upon clinical determinations.”
4-5.
“a

Id.

at

The court previously found that confidentiality is
hallmark

of

and

mental-health treatment.”
1210.

a

necessary

condition

for

Braggs, 257 F. Supp. 3d at

Inmates “often do not feel safe sharing their

mental-health issues in the presence of correctional
officers or other prisoners because what they share with
the mental-health staff may make it easier for others to
exploit them; as a result, the lack of confidentiality
undermines the effectiveness and quality of counseling
sessions.”

Id.

However, the court also found that some

ADOC facilities do not have mental-health offices where
confidential counseling can occur.

See id.

Plaintiff

expert Dr. Burns credibly opined during her testimony on
inpatient treatment that therapeutic groups should also
be conducted in confidential settings: “it is important
that there not be outside bystanders, but the people in
the group maintain confidentiality within the group with

41

one another.”

Apr. 27, 2018, Trial Tr. (doc. no. 2696)

at 127.

ii. Dispute
The

plaintiffs

assert

that

the

treatment

space

currently available at the mental-health treatment hub
prisons

is

inadequate.

For

support,

they

point

to

testimony to that effect by ADOC Director of Psychiatry
Dr. Kern, defense expert Dr. Patterson, and plaintiff
expert

Dr.

Burns.

During

the

liability

trial,

Dr.

Patterson credibly opined that the prisons “don’t have
adequate treatment space” and that “[t]here are issues
with confidentiality.”
no. 1277) at 138.

Jan. 31, 2017, Trial Tr. (doc.

At the hearing on the defendants’

remedial plan for inpatient treatment, Dr. Kern similarly
opined that an increase in confidential treatment space
for RTU and SU patients is necessary.
Trial Tr. (doc. no. 2695) at 107.

See Apr. 25, 2018,

He further stated that

he was unaware of any specific plans by ADOC to remedy
this space problem.

See id.

42

In addition, Dr. Burns

testified

specifically

insufficient space.
that

the

SU

at

about

certain

examples

of

For instance, she credibly opined

Kilby

lacks

space

for

confidential

counseling appointments and confidential group therapy.
See Apr. 27, 2018, Trial Tr. (doc. no. 2696) at 132-33.
She

also

credibly

opined

that

ADOC

currently

has

treatment space for only one confidential group at a time
in the Donaldson RTU--which is insufficient to provide
10 hours of structured therapeutic time per week to all
144 inmates housed therein--and for only non-confidential
groups in the Bullock SU.8

See id. at 128-29.

The

plaintiffs assert that failure to require ADOC to remedy
the lack of adequate treatment space would undermine
other

remedial

measures

to

improve

treatment

in

the

8. Dr. Kern testified that two mental-health groups
could occur simultaneously in the Bullock SU, though did
not opine on whether such an arrangement could ensure
confidentiality. See Apr. 25, 2018, Trial Tr. (doc. no.
2695) at 56. He also testified that the Donaldson RTU
has space for “group activity,” though did not specify
whether that space allows for confidentiality either or
whether it allows for enough simultaneous groups to meet
ADOC’s commitments. Apr. 24, 2018, Trial Tr. (doc. no.
1939) at 42.
43

inpatient units. Proceeding without additional treatment
space, they argue, would set ADOC up to fail.
The defendants’ proposal does not include any plans
regarding treatment space at any of the treatment hubs.
The

defendants

stated

at

the

hearing

on

inpatient

treatment that the sufficiency of space to accommodate
the programming and out-of-cell requirements to which
they have agreed is “a challenge in terms of scheduling”
but not “necessarily ... a concern” for the defendants.
June 18, 2018, Oral Arg. Tr. (doc. no. 1905) at 54-55.
The defendants further stated that ADOC has acquired
‘therapeutic

furniture,’

which

is

furniture

that

restrains patients during therapy sessions and thereby
allows

the

sessions

correctional staff.

iii.

to

be

conducted

with

fewer

Id. at 54.

The Court’s Resolution

The court finds the defendants’ proposal fails to
address adequately the consensus among expert witnesses
that, overall, the mental-health units lack sufficient

44

treatment space.
defendants

to

The court will therefore require the

conduct

an

assessment

as

to

how

much

additional treatment space is needed and to propose a
plan to address the additional need.
Group
treatment

therapy,
in

a

particularly

correctional

important

institutions

form

with

of

finite

resources, see Braggs, 257 F. Supp. 3d at 1211, cannot
occur

unless

there

is

enough

space

and

cannot

be

effective unless that space allows for confidentiality,
see id. at 1210.

In accordance with national standards,

ADOC has agreed to provide significantly more out-of-cell
time than it has previously provided, and in settings
that

provide

for

confidentiality.

To

fulfill

this

commitment, ADOC must have enough space in which to do
so,

but

witnesses

for

both

parties

testified

that

currently it does not.
Moreover,

the

experts’

opinions

that

ADOC

lacks

sufficient treatment space do not account for the court’s
requirement today that ADOC prepare for the projected
increase in the number of patients referred for inpatient

45

care.

If, as Dr. Patterson, Dr. Kern, and Dr. Burns all

testified, the current space is not enough to provide
minimally

adequate

treatment

when

the

existing

mental-health units are at capacity, it is certain to be
insufficient for the additional inpatient beds required
to meet the projected need.
While

‘therapeutic

furniture,’

otherwise

called

‘restraining desks’ or ‘restraining chairs,’ is a helpful
addition to ADOC’s mental-health units, the court fails
to see how it addresses the issue of sufficiency of space.
Therapeutic furniture helps to address lack of staff and
reduce

“the

amount

treatment groups.
2695)

at

116.

significant

of

security”

necessary

to

run

Apr. 25, 2018, Trial Tr. (doc. no.
But

bearing

this
on

would

the

not

amount

of

appear

to

physical

have
space

necessary to provide enough confidential treatment to all
patients.
The court finds that in order to provide minimally
adequate treatment in inpatient units, ADOC must plan for
where it will provide that treatment.

46

Failing to do so

will result in the harm caused by lack of treatment:
“without

out-of-cell

housing

severely

time

and

mentally

effective

ill

treatment,

prisoners

in

a

mental-health unit is tantamount to ‘warehousing’ the
mentally ill.”
omitted).

Braggs, 257 F. Supp. 3d at 1214 (citation

The

court

cannot

tell

from

the

record,

however, how much new space is needed; indeed, out of
deference, this how-much decision should be first tackled
by the defendants.

Accordingly, the court will require

the defendants to assess, in consultation with their
mental-health

experts,

how

much

additional

treatment

space is needed and to produce a plan as to where ADOC
will

provide

out-of-cell

confidential

treatment

to

patients in the SUs and RTUs. The assessment must account
for where all hours of structured out-of-cell treatment
per patient per week can occur and how these spaces will
provide adequate confidentiality to ensure meaningful
treatment in group and individual settings.

It must also

include explicit consideration of the projected increase
in patients identified for inpatient treatment according

47

to the expert consensus or according to a new needs
assessment the defendants will conduct, as described
earlier in this opinion.

iv. PLRA Findings
The court now finds that this relief satisfies the
‘need-narrowness-intrusiveness’

requirement

of

§ 3626(a)(1)(A) of the PLRA.

Without enough treatment

space,

to

ADOC

will

be

unable

provide

a

minimally

adequate amount of therapeutic activities to patients in
mental-health units, undermining one of the remedial
measures most fundamental to remedying the constitutional
violation found.

The court anticipates that additional

treatment space will be necessary, particularly if the
defendants’

plan

to

address

the

need

treatment includes adding more beds.

for

inpatient

However, allowing

the defendants considerable deference, the court does not
require construction of additional treatment space, and
instead takes the narrowest approach of requiring the
defendants to conduct their own assessment and propose

48

their own plan.

The court’s requirement is narrowly

drawn, extends no further than necessary to remedy the
constitutional

violation

found,

and

is

the

least

intrusive means of doing so.

C. Suicide-Resistant Cells
i. Findings
The

court

previously

found

all

ADOC

mental-health unit cells are suicide-resistant.

See

Braggs, 257 F. Supp. 3d at 1227.

that

not

Patients in these units

have repeatedly succeeded in hanging themselves from
tie-off points in the cells.

While it may be impossible

to make any cell fully suicide-proof, the court saw
firsthand during its visit to the Bullock SU in February
2017 that “sprinkler heads are located directly above the
sink

and

the

toilet,

making

it

easy

for

suicidal

prisoners to climb up to tie a ligature on the sprinkler
head.”

Id.

construction

The serious risk of harm posed by the
of

these

cells

was

realized

when

Jamie

Wallace, a mentally ill inmate, took his own life in an

49

SU cell shortly after testifying in the liability trial.
“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.”
Id. at 1186.

ii. Dispute
The dispute regarding the design of SU cells appears
to be centered on whether the issue should be addressed
now or in a later stage of this litigation.

In their

briefing, the defendants maintain that this issue is
outside the scope of the remedial phase on inpatient
treatment.

They

contend

that

the

topic

of

suicide-resistant cells in SUs should be addressed when
the parties resolve suicide-prevention matters on the
whole.

See Defendants’ Reply in Support of Proposed

Opinion (doc. no. 1849) at 12.

Meanwhile, the plaintiffs

seek an order now that all cells used for stabilization
placements be made suicide-resistant (that is, without

50

tie-off points) and have cell door windows measuring at
least 24 by 18 inches.

See Plaintiffs’ Proposed Opinion

(doc. no. 1840) at 28-29.
On September 6, 2019, the parties filed stipulations
regarding

suicide-prevention

measures.

See

Prevention Stipulations (doc. no. 2606-1).

Suicide

Among other

provisions, the stipulations include that “ADOC will
determine, in collaboration with Dr. Mary Perrien, the
appropriate number of suicide resistant cells for each
ADOC major facility.

The number of suicide resistant

cells for each ADOC major facility will be subject to the
approval of the mental health monitor or, if there is not
yet a mental health monitor, Plaintiffs’ expert.”

Id.

at 6.
During

an

on-the-record

hearing

about

these

stipulations on December 6, 2019, the plaintiffs stated
that

this

provision

does

not

suicide-resistant cells in SUs.
Tr. (doc. no. 2686) at 74-75.

resolve

the

issue

of

See Dec. 6, 2019, Hr’g

The parties clarified that

defense consultant Dr. Perrien’s analysis will be limited

51

to whether ADOC needs to create additional crisis cells,
not whether or which of the existing cells must be made
suicide-resistant.

See id.

Because many of the SU cells

are currently used as crisis cells, and the parties have
already

agreed

that

all

crisis

cells

must

be

suicide-resistant, some SU cells will necessarily be made
suicide-resistant.

However, whether the court should

require

remaining

that

additional

SU

the

cells

that

SU

ADOC

cells--as
may

create

well
in

as
the

future--be suicide-resistant remains in dispute. Despite
the

defendants’

earlier

contention

that

the

suicide-prevention portion of the remedial phase was the
proper

phase

defendants

in

which

presented

no

to

address

argument

or

this

issue,

evidence

at

the
the

December 6 hearing about the parties’ suicide-prevention
agreements that SU cells need not be suicide-resistant.

iii. The Court’s Resolution
Crediting the opinions of both ADOC Director of
Psychiatry Dr. Kern and plaintiff expert Dr. Burns, and

52

with no contradicting evidence, the court finds that all
SU cells must be suicide-resistant.

See Apr. 25, 2018,

Trial Tr. (doc. no. 2695) at 107; Apr. 27, 2018, Trial
Tr. (doc. no. 2696) at 126.
the

remedial

phase

suicide-prevention
make

any

nor

measures

substantive

Neither in this portion of
in

the

generally

argument

or

hearing
did

present

on

defendants
any

expert

testimony that this measure is unnecessary.
SU cells are intended to house 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.”

Braggs, 257 F. Supp. 3d at 1183.

To

address the obvious and substantial risk of serious harm
to these patients, ADOC must eliminate the structural
elements that enable patients to commit suicide while
housed in cells intended for intensive treatment.

Cells

shall be considered suicide-resistant if they meet the
requirements to which the parties have already agreed
under their suicide-prevention agreement, see Suicide

53

Prevention

Stipulations

(doc.

no.

2606-1)

at

6.9

Alternatively, the court is willing to consider other
equally

effective

measures

to

make

SU

cells

suicide-resistant, should the defendants have a different
proposal.

iv. PLRA Findings
This

relief

satisfies

‘needs-narrowness-intrusiveness’
§ 3626(a)(1)(A)

of

suicide-resistant

the
is

PLRA.
essential

the

requirement
Making
to

all

SU

addressing

of
cells
the

substantial risk of fatal harm to patients who are placed
in these cells precisely because they are likely to
engage in self-harm.

As discussed, the defendants have

already agreed that SU cells used as suicide watch must

9. The suicide-prevention stipulations include that
“[s]uicide watch cells shall be considered suicide
resistant if they meet the requirements set forth in
section III(B) of the ADA Report.” Suicide Prevention
Stipulations (doc. no. 2606-1) at 6. This stipulation
references
the
standards
for
making
cells
suicide-resistant outlined by consultants as part of
their evaluation of ADOC’s facilities in Phase I of this
case. See ADA Report (doc. no. 2635-1) at 42.
54

be suicide-resistant. The relief required is, therefore,
narrowly drawn to include only the remaining SU cells as
well as any additional SU cells that ADOC proposes to
create in response to today’s remedial order.

The court

also defers to the metrics to which the defendants have
already agreed under the suicide-prevention agreement to
ensure

a

cell

is

suicide-resistant.

See

Suicide

Prevention Stipulations (doc. no. 2606-1) at 6.
court

has

previously

held,

“where,

as

As the

here,

the

provisions of relief ordered by a court are adopted from
an agreement jointly drafted and reached by the parties,
it is compelling evidence that the provisions comply with
the needs-narrowness-intrusiveness criteria.”
Dunn,

383

F.

Supp.

3d

1218,

1253

(Thompson, J.) (citations omitted).
court

also

propose

leaves

alternative

open

the

measures

(M.D.

allowing even more flexibility.

Ala.

2019)

Nonetheless, the

possibility
to

Braggs v.

meet

for

the

ADOC

same

to

end,

The court finds that

this relief is narrowly drawn, extends no further than

55

necessary to remedy the constitutional violation found,
and is the least intrusive means of doing so.

D. Heat Management
i. Findings
It

is

medications

undisputed
are

at

that
risk

patients
of

on

psychotropic

overheating,

as

such

medications “impact a person’s temperature regulation
center, and ... make[] them prone to things like heat
stroke, heat prostration, and in severe cases, death.”
Apr. 27, 2018, Trial Tr. (doc. no. 1817) at 120 (Dr.
Burns testifying).

Plaintiff expert Dr. Burns explained

that

medications

psychotropic

cause

individuals

to

overheat without their realizing it, such that “it is
difficult to expect that they would be able to recognize
when they need to seek assistance ....”

Id. at 133.

The

danger of overheating is an “important reason” why ADOC
Director of Psychiatry Dr. Kern agreed that RTUs and SUs
should be air-conditioned.
(doc. no. 2695) at 105.

Apr. 25, 2018, Trial Tr.

While Tutwiler and Bullock’s

56

mental-health units are apparently air-conditioned, see
June 18, 2018, Oral Arg. Tr. (doc. no. 1905) at 64-65,
Donaldson, the site of mental-health units housing as
many as 96 patients total, is not, see id. at 66.

It is

not clear whether Kilby, which has 16 SU beds, is airconditioned.

ii. Dispute
To address this serious risk, the plaintiffs seek an
order

requiring

conditioning

in

the
all

defendants

inpatient

to

install

air

units.

The

treatment

defendants, however, again argue that the issue of heat
management is outside the scope of this remedial phase.
The

defendants

further

insist

that

installing

air

conditioning is an unnecessarily burdensome task and that
inmates

experiencing

accommodations

overheating

procedure

under

the

can

use

the

Americans

with

Disabilities Act (ADA), 42 U.S.C. § 12131 et seq., to
request and obtain relief.
defendants

assert,

an

Through that procedure, the

individual

57

in

need

of

an

accommodation due to their heat sensitivity may make a
request for an accommodation.
1650) at 1.

See Joint Report (doc. no.

Upon making such a request, the inmate

“should be evaluated by qualified medical clinicians, in
consultation with the inmate’s mental health provider,
to determine if an accommodation is appropriate.”
at 1.

Id.

If an accommodation is determined to be medically

appropriate, “then ADOC should grant and implement that
accommodation.”

Id. at 2.

The defendants do not give

details as to what that accommodation may be.
This procedure, the plaintiffs argue, is inadequate
because,

as

explained

by

Dr.

Burns,

patients

on

psychotropic medications are typically not aware that
they are overheating and in need of any accommodation.
The plaintiffs further contend that, even if a patient
were

to

utilize

the

accommodations

process,

the

accommodation may still be inadequate--should a clinician
determine the required accommodation is to move that
patient

out

of

an

inpatient

treatment

unit

to

an

air-conditioned unit, he or she may no longer receive

58

residential-level mental-health treatment.
2018, Trial Tr. (doc. no. 1817) at 125.
ADA

procedure

conditioning

may
and

require
inpatient

a

See Apr. 27,

Thus, use of the

trade-off

between

mental-health

air

treatment.

Further, the plaintiffs argue, with nearly 100 % of
patients in inpatient treatment units taking psychotropic
medication,

in

the

event

clinically

determined

to

that

all

require

residents

are

air-conditioned

housing, it is unclear how ADOC would accommodate the
need.
In

addition

to

the

ADA

process,

the

defendants

pointed during the hearing on inpatient treatment to
ADOC’s existing heat-management policy, which provides
for regular monitoring of the temperature in segregation
units when the outside temperature is higher than 80
degrees.

Joint Ex. 118, Admin. Reg. § 619 (doc. no.

1038-141)

at

2.

Per

this

regulation,

if

the

cell

temperature detected exceeds 90 degrees in a segregation
unit, staff must automatically provide accommodations
such as using fans to increase ventilation and airflow,

59

providing

increased

amounts

of

fluids

and

ice,

and

allowing additional showers to provide cooling.

See id.

These

to

requirements

mental-health
broadly

do

units,

states

that:

not

appear

however.
“The

to

extend

Instead,

Director

of

the

the

policy

Treatment

and

Wardens will ensure that measures to reduce sun/heat
exposure risks for inmates taking psychotropic medication
are initiated and maintained at all ADOC institutions.”
Id.

The policy also requires that nurses conduct inmate

education

with

those

on

psychotropic

medications

by

informing them of the risks of overheating, and that, in
some situations, inmates be provided sunscreen.

Id. at

2-3.

iii. The Court’s Resolution
As

an

initial

matter,

the

court

rejects

the

defendants’ position that this issue is outside the scope
of the inpatient treatment remedy, for maintaining a safe
environment

for

patients

minimally adequate care.

is

essential

to

providing

While the court will not at

60

this time require ADOC to install air conditioning in all
mental-health

units,

the

court

will

require

the

defendants to create a heat management plan to address
the substantial risk of serious harm to patients on
psychotropic medications in these units.
The court has serious doubts about ADOC’s ability to
adequately address the risk to patients through means
less than air conditioning.
plaintiffs

that

the

The court agrees with the

ADA

process

cannot

protect

individuals who do not realize when they are overheating
and, thus, do not know to request an accommodation.
Further, with nearly 100 % of patients in mental-health
units

taking

psychotropic

medications,

accommodating

individual patients by moving them into air-conditioned
units one by one is both illogical and inadequate if it
results in their loss of inpatient care.

In fact, as the

plaintiffs rightly noted, to do so may even be impossible
as it would likely require the rehousing of entire units
of patients.

61

The court is very concerned about the near certainty
of these logistical impediments to ensuring adequate
temperatures

in

these

units

while

simultaneously

providing inpatient treatment to all who need it.

ADOC’s

failure to fulfill one of these requirements in pursuit
of

fulfilling

the

other

will

result

in

additional

violations of either the ADA, or of the Eighth Amendment,
or both.

Nonetheless, in deference to the defendants,

the court will order them simply to devise a plan and
procedures to address the serious risk posed by high
temperatures in the mental-health units.

The defendants

should specifically address the court’s concerns about
accommodating
overheating,

individuals
the

risk

who
that

do

not

those

know

they

accommodated

are
by

reassignment to air-conditioned housing will lose access
to

their

inpatient

mental-health

treatment,

and

the

logistics of providing adequate accommodations to an
entire unit at once.
rely

on

measures

To the extent that ADOC intends to
short

of

air

conditioning,

the

defendants should give details as to how the measures

62

they propose will ensure temperatures safe for patients
on psychotropic medications. For example, the defendants
say that, if a segregation cell temperature exceeds 90
degrees, staff will automatically provide fans, increase
amounts of fluids and ice provided to the inmate, and
allow additional showers.
provided

no

information

However, the defendants have
of

how

ADOC

will

reliably

determine when a particular cell exceeds 90 degrees and
no information of how ADOC will determine, should a cell
exceed 90 degrees, whether the measures it has taken have
been

adequate

to

prevent

a

particular

patient’s

overheating, for, depending on how extreme the weather
conditions are, the measures may or may not be adequate
to

redress

defendants

the
should

above-90-degree
also

evaluate

temperature.
the

feasibility

The
of

installing air conditioning in the mental-health units
in any of the new facilities the ADOC plans to construct.

63

iv. PLRA Findings
The court now finds that this relief satisfies the
‘needs-narrowness-intrusiveness’
§ 3626(a)(1)(A) of the PLRA.

requirement

of

First, addressing the risk

of overheating is essential to ensuring the safety of
those in inpatient units and, through the promulgation
of its existing policies, ADOC itself has acknowledged
that risk.

Second, ADOC has already adequately addressed

the issue of heat management in Tutwiler and Bullock
mental-health units by installing air conditioning.
relief

required

is

therefore

limited

to

the

The

units

containing inpatient beds at Donaldson, and possibly at
Kilby, and any additional mental-health units ADOC may
create

at

other

constructed.
intrusive

prisons,

including

those

newly

Third, the court finds the relief the least

possible

as

it

gives

opportunity to devise a solution.

the

defendants

an

The court therefore

finds that this relief is narrowly drawn, extends no
further

than

necessary

to

64

remedy

the

constitutional

violation found, and is the least intrusive means of
doing so.

E. Admissions Criteria
i. Findings
In the liability opinion, the court credited defense
expert Patterson’s opinion that the RTU admission (and
discharge)

process

is

flawed

and

that

these

flaws

contribute to under-identification of inmates needing
residential treatment.
1205.

See Braggs, 257 F. Supp. 3d at

In particular, inmates repeatedly sent to the SU

should be considered for a higher level of care, such as
the RTU, to receive longer-term intensive treatment.
id.

Instead,

the

court

found

that

ADOC

See

regularly

releases these individuals to general population, and
they consequently cycle between general population and
crisis placements.

See id.

This pattern contributes to

ADOC’s failure to provide inpatient treatment to those
who need it, despite the existence of empty inpatient
treatment beds.

See id.

65

ii. Dispute
Since

the

briefing

in

this

remedial

phase,

the

parties have reached several stipulations addressing this
topic.

The

stipulations

about

psychotherapy

and

confidentiality (doc. no. 1899-1) appear to directly
address the plaintiffs’ concerns that the defendants
should be clear in their policies about the following:
whether inmates can move between the various levels of
care, what the possible discharge placements are from
each level of care, that inmates can enter into the
continuum of inpatient care at any level, that stays in
SUs should be brief, that some inmates may remain in RTUs
indefinitely, and that prolonged SU placements should
lead

to

a

higher

level

of

inpatient

care.

These

stipulations also outline the types of services patients
will receive in SUs and RTUs, including the number of
clinical encounters and counseling sessions, and provide
processes for ensuring periodic re-evaluation of the
appropriateness

of

a

patient’s

66

current

level

of

treatment.

See id.

The parties have also reached other

stipulations to improve continuity of care, including,
for example, that treatment teams will meet to review and
update treatment plans during any movement between, in,
or

out

of

any

inpatient

unit.

See

Individualized

Treatment Planning Stipulations (doc. no. 1865-1) at 15.
The remaining dispute under the topic of admissions
to mental-health units is about the admissions criteria
themselves.

The

defendants’

proposed

plan

does

not

include a plan to change the existing criteria.

The

defendants

are

adequate

argue

that

because

ADOC’s

they

were

constitutionally deficient.
court

to

require

the

admissions criteria.

current
not

criteria
found

to

be

The plaintiffs urge the

defendants

to

establish

new

They argue the existing criteria

are inadequate on their face, resulting in the flawed RTU
admission management the court described in the liability
opinion.
plaintiffs

See Braggs, 257 F. Supp. 3d at 1205.
point

to

Dr. Burns’s

testimony

that,

The
in

general, admissions and discharge criteria in inpatient

67

care units should be sufficiently clear such that both
patients and staff know what to expect in each level.
See Apr. 27, 2018, Trial Tr. (doc. no. 1817) at 26-27,
30.

According to Dr. Burns, clear criteria help staff

determine

when

they

should

make

referrals,

who

is

eligible for transfer to an RTU or SU, how long patients
are anticipated to stay in any given environment, and how
patients should spend their time in each environment.
See id. at 26-27.

For patients, she opined, clear

criteria help them understand what is required for them
to move from more restrictive housing placements--SU and
the lower RTU levels--to less restrictive environments.
See id. at 29-31.

The plaintiffs assert that ADOC’s

existing RTU criteria, see Joint Ex. 135, Admin. Reg. §
633 (doc. no. 1038-167),10 are “so vague to be basically
10. The existing administrative regulations provide
the following criteria for each RTU level: (1) RTU level
one
is
for
patients
“experiencing
problems
in
functioning” and/or “demonstrating the inability to
control impulses” as well as those admitted to the RTU
and awaiting an evaluation; (2) RTU level two is for
patients “unable to participate in total RTU program due
to limited impulse control” or “cognitive impairment,”
as well as those “who could benefit from less intensive
68

meaningless.”

June 18, 2018, Oral Arg. Tr. (doc.

no.

1905) at 77.
The defendants agree with the plaintiffs that ADOC’s
existing criteria are “loose” and “not detailed.”
18, 2018, Oral Arg. Tr. (doc. no. 1905) at 79.

June

However,

they assert that, because the determination of what level
of treatment a patient requires is a clinical one, the
criteria should have this level of flexibility.

See id.

iii. The Court’s Resolution
Without expert testimony as to the adequacy of ADOC’s
existing admissions criteria, the court cannot, at this
time, find the criteria inadequate.
credible

Dr.

Burns’s

testimony

The court finds
that,

to

ensure

consistency in referral and discharge decisions, the

treatment involvement and small group interaction”; and
(3) RTU level three is for “[i]nmates able to follow
simple concrete instructions,” “[i]nmates, with support,
able to comprehend and comply with institutional
regulations,” “inmates able to tolerate low stress
activities in group situations” and “inmates [who] have
no recent episode of violent behavior toward self or
others.”
Joint Ex. 135, Admin. Reg. § 633 (doc. no.
1038-167) at 18.
69

criteria

should

clearly

describe

what

level

of

functioning and need each level of inpatient care is
intended

to

address.

clinical

expertise

to

However,

the

extrapolate

court
from

lacks

Dr.

the

Burns’s

opinion as to exactly how ADOC’s existing policies are
inadequate.

The

court

is

unable

to

determine

when

consistency must give way to flexibility and vice versa,
for the court, using its common sense, sees value in both
consistency

and

flexibility.

Therefore,

the

court

declines to enter a remedial order on the issue at this
time.

The court believes that the plaintiffs are asking

the court to delve too much into detailed discretionary
clinical judgment.

The court also believes it is wise

to wait and see how the various stipulations to which the
parties have agreed play out, albeit perhaps indirectly,
with regard to issue of RTU admission; it may be that the
deficiencies the plaintiffs have identified will resolve
themselves.

Otherwise,

monitoring

deficiencies, if any.

70

might

reveal

F. Privileges
i. Findings
In the liability opinion, the court found that, due
to

“an

unduly

harsh

and

punitive

practice

limiting

property,” patients in mental-health units “do not have
books to read or other things to keep them engaged while
spending the vast majority of their time in their cells.”
Braggs, F. Supp. 3d 1171 at 1214-15. This practice “makes
mental-health units far from therapeutic and exacerbates
prisoners’ idleness.”

Id. at 1214.

The court observed

firsthand during its visits to Bullock and Donaldson that
in

the

inpatient

units,

“the

majority

of

prisoners ... were lying in their cells, often in a fetal
position and facing the wall” with “no way to engage in
any remotely meaningful activity in the cell.”
1215.

71

Id. at

ii. Dispute
The parties again disagree on whether the defendants
are obligated to remedy this issue.

The defendants’ plan

makes no mention of privileges or access to property for
patients

housed

in

the

mental-health

units.

The

defendants maintain that the issue is outside the scope
of this remedial phase.

The existing administrative

regulations provide some guidance as to what privileges
patients can expect in each level of the RTU,11 including
regarding

the

location

administration.

of

patients

and

medication

See Joint Ex. 135, Admin. Reg. § 633

(doc. no. 1038-167) at 18.
that

meals

in

RTU

The regulations also state

level

one

may

have

“[l]imited

personal property,” in RTU level two may have “[p]roperty
greater than that of Level 1 inmates but less than that
of Level 3 inmates,” and in RTU level three may have “the
same

property

as

general

population

inmates,”

possible limitations on cans or caffeinated coffee.

with
Id.

11. This regulation includes a level four RTU, which
appears to no longer exist.
72

The plaintiffs argue that the liability findings
support a remedial order that the defendants define the
privileges and access to property to which patients in
the mental-health units are entitled.

The plaintiffs

point to Dr. Burns’s testimony that the following issues
should be “thought through ahead of time and spelled
out,” see Apr. 27, 2018, Trial Tr. (doc. no. 2696) at 63,
for each level of inpatient care: which types of property
patients can have; whether and with what restrictions
patients are entitled to visitation, phone, mail, and
commissary privileges; whether patients can leave their
cells without handcuffs and shackles; which patients must
participate

in

group

activity

using

therapeutic

furniture; and whether patients are required to eat in
their cells.

iii.

The Court’s Resolution

The court declines to enter the order the plaintiffs
seek requiring the defendants to define privileges in the
inpatient units.

While the court is very concerned about

73

the

detrimental

effects

of

in-cell

idleness

in

particular, ADOC already has a policy in place allowing
privileges in these units.
criteria,

the

court

In addition, like admissions

recognizes

that

entitlement

to

privileges must be based on clinical determinations.

As

Dr. Burns credibly testified, the privileges to which
patients are entitled are based on “level of functioning”
and “clinical condition.”

Apr. 27, 2018, Trial Tr. at

88. While the harsh lack of property the court previously
observed in mental-health units is deeply concerning, the
court

assumes

planning

in

that,

as

inpatient

part

of

units,

improved

clinicians

treatment
will

now

recommend appropriate in-cell activities for patients and
that

ADOC

personnel

recommendations.

will

carry

out

these

clinical

In short, the court believes this issue

should, and will, be addressed as part of the overall
improved treatment planning that will result from other
remedial measures.
As discussed, it is clear that depriving patients of
things

to

do

in

cell--such

74

as

reading

and

writing--undermines the therapeutic nature of the units.
Without any privileges, the mental-health units will
remain ‘segregation-like,’ which the court has already
found

to

cause

worsening

symptoms

for

mentally

ill

inmates and underutilization of residential treatment.
However,

the

court

will

mental-health

staff

by

not

take

entering

remedial orders in this regard.

on

the

extremely

role

of

detailed

Instead, to the extent

these deficiencies still remain, they could be addressed
through monitoring.

G. Natural Light
i. Findings
It is undisputed that access to natural light has
positive effects on both mental and physical health.
Plaintiff expert Dr. Burns testified during the inpatient
treatment

hearing

that

exposure

to

natural

light

is

“important for mental health and well-being” as well as
“for vitamin reasons.”

Apr. 27, 2018, Trial Tr. at 126.

Dr. Kern testified that it is “a good general plan to

75

increase natural light” in mental-health units. Apr. 25,
2018, Trial Tr. (doc. no. 2695) at 106.

ii. Dispute
Relying on Dr. Burns’s testimony, the plaintiffs seek
an order requiring the defendants to “ensure that all
mental-health units within ADOC have adequate natural
lighting.”
at 28.

Plaintiffs’ Proposed Opinion (doc. no. 1840)

The plaintiffs also assert that natural light is

important to improve the segregation-like atmosphere in
inpatient treatment units.

See June 18, 2018, Oral Arg.

Tr. (doc. no. 1905) at 62.

The defendants again argue

that the issue is outside the scope of the inpatient
treatment remedy.

iii.

The Court’s Resolution

As the court held in the liability opinion, patients
in

mental-health

units

“are

at

a

higher

risk

of

decompensation ... if their housing environment is not
therapeutic.”

Braggs, 257 F. Supp. 3d at 1212.

76

Thus,

in renovating existing prisons under the Phase 1 ADA plan
and building new ones, ADOC should take into account the
important

effect

of

natural

light

on

the

overall

environment of mental-health units and the health of
those residing therein.

The court will not enter a

remedial order on this issue, however, as the record does
not contain sufficient evidence for the court to find
that requiring ADOC to provide more natural light in the
units

meets

the

needs-narrowness-intrusiveness

requirement of the PLRA, 18 U.S.C. § 3626(a)(1)(A).

H. Additional Training for Correctional Officers
i. Findings
As

discussed,

the

court

found

in

the

liability

opinion that ADOC fails to identify those in need of
treatment both during and after the intake process.

A

functioning identification system relies, in part, on the
ability of correctional officers to observe and identify
mental-health

symptoms

mental-health care.

and

refer

inmates

for

See Braggs, 257 F. Supp. 3d at

77

1203-1204.

For this to happen, facilities must have

sufficient correctional staffing, but also, officers must
know how to recognize behavior related to mental illness.
In the liability trial, plaintiff expert Dr. Craig Haney
credibly opined that training correctional officers to
identify

mental-health

symptoms

and

make

referrals

improves the accessibility of mental-health care.
Jan. 19, 2017, Trial Tr. (doc. no. 1266) at 30-31.

See
On

the other end, plaintiff expert Dr. Burns testified that
correctional staff interacting directly with patients who
have made it into inpatient units should receive training
on specific skills for working in those units.

See Apr.

27, 2018, Trial Tr. (doc. no. 2696) at 131-32.

ii. Dispute
Prior to the hearing on inpatient treatment, the
parties agreed to stipulations regarding training for
“[a]ll persons working within any ADOC major facility who
have any direct contact with inmates.”
Stipulations (doc. no. 1821-1) at 1.

78

See Referral

Pursuant to these

stipulations, ADOC and its mental-health vendor were to
develop

a

‘Comprehensive

Mental

Health

Training

Curriculum’ to include curricula about identifying mental
illness,

the

mental-health

services

available

within

ADOC, and the process for referring inmates for mental
health evaluations.

See id. at 2-3.

The agreement

requires that plaintiff expert Dr. Burns review this
proposal and that ADOC implement the finalized training
no later than February 1, 2019.

See id. at 3.

All

correctional staff must complete the training within 30
days of assignment to a major ADOC facility.
6-7.

See id. at

In an on-the-record hearing on December 6, 2019,

the parties represented that, while this training had not
been finalized, it was likely to be approved by Dr. Burns
shortly thereafter.

See Dec. 6, 2019, Status Conf. Tr.

(doc. no. 2686) at 62.
In their proposal, filed before this stipulation,
the defendants propose training correctional staff in the
new mental-health classification system, including about
proper documentation in treatment plans and progress

79

notes.

See Defendants’ Phase 2A Proposed Remedial Plan

on Identification, Classification, and Residential Unit
Out-of-Cell Time and Treatment (doc. no. 1594) at 21.
This new training would not be implemented until all of
the court’s remedial orders have been entered.

In the

interim, the defendants propose continuing to provide the
training prescribed by existing ADOC regulations.
id.

See

These regulations prescribe a two-day training for

staff

routinely

assigned

to

SU,

RTU,

infirmary,

and

segregation units, which includes topics such as “crisis
intervention

strategies,”

“confidentiality,”

and

“watches and the use of restraints for mental health
reasons.”

Joint Ex. 98, Admin. Reg. § 608 (doc. no.

1038-120) at 3-4.
The plaintiffs argue that the training included in
the defendants’ original proposal is insufficient because
it

does

not

include

additional

training

for

ADOC

correctional staff working in mental-health units.

The

plaintiffs assert that training should ensure staff have
“enhanced

interpersonal

communication

80

and

crisis

de-escalation skills,” “a better understanding of the
symptoms of mental illness” and knowledge of how “to use
restraints.”
1840)

at

Plaintiffs’ Proposed Opinion (doc. no.

29.

Despite

the

stipulation

creating

a

‘Comprehensive Mental Health Training,’ the issue of
specific training for officers in mental-health units
remains unresolved according to representations made by
the plaintiffs during the December 6, 2019, hearing.

See

Dec. 6, 2019, Hr’g Tr. (doc. no. 2686) at 67.

iii. The Court’s Resolution
The court agrees with the plaintiffs that training
correctional officers is important to implementing the
remedial measures and ensuring a functional mental-health
care system.

The court fails to see, however, how the

existing training and the nearly finalized ‘Comprehensive
Mental

Health

combination,

Training

address

Curriculum’

the

topics

do

not,

requested

by

in
the

plaintiffs; assuming the topics in the existing training
continue

to

be

included,

every

81

topic

on

which

the

plaintiffs assert correctional officers in RTUs and SUs
should be trained appears to be included.
defers

its

determination

of

this

issue

The court
to

when

it

determines, in the fall of 2020, whether the parties’
agreements and stipulations regarding training meet the
requirements of the PLRA, 18 U.S.C. § 3626(a)(1)(A).

I. Monitoring
i. Dispute
The plaintiffs seek an order appointing a security
and

a

mental-health

monitor,

to

be

paid

by

the

defendants, and giving those monitors the authority to
“visit the facilities, speak with staff and prisoners,
review

logs

and

other

documents,

as

necessary,

to

determine whether prisoners are being timely referred and
transferred to mental-health units; whether there are
delays or waitlists for transfers to mental-health units;
how long prisoners are staying in mental-health units;
to which types of units prisoners are discharged from
mental-health units; how long prisoners with serious

82

mental illness remain in segregation; and whether there
are

any

obstacles

compliance.”
1840) at 30-31.

to

achieving

constitutional

Plaintiffs’ Proposed Opinion (doc. no.
The plaintiffs propose that the monitors

be allowed to conduct a variety of evaluations to assess
these

issues.

requiring

ADOC

The
to

plaintiffs

produce

also

multiple

seek

an

monthly

order

reports,

ranging from caseload statistics to duty logs.

“To

ensure the eventual transition of monitoring” to the
Office of Health Services (OHS), the plaintiffs propose
including OHS staff in these monitoring processes. Id.
at 38.
The defendants assert that the court should require
no

monitoring

or

reporting

because

ADOC

should

be

accorded deference in the implementation of changes to
inpatient treatment units and because the requirement the
plaintiffs seek is overly burdensome.

83

ii.

The Court’s Resolution

The court agrees with the plaintiffs that it is
necessary

to

compliance

devise

with

the

a

monitoring

remedies

the

scheme
court

to

ensure

will

order.

However, the court will reserve the issue of monitoring
at this time for a global monitoring resolution at a
later date.
***
Therefore, with regard to inpatient mental-health
treatment and as discussed and outlined above, it is
ORDERED that, on or before 5:00 p.m. on July 1, 2020, the
defendants, with input from their experts, are to submit
the following to the court:

(1) a plan to ensure the

creation of more and adequate inpatient treatment beds;
(2) a plan to ensure the creation of more and adequate
treatment

space;

suicide-resistant;

(3)
and

a

plan
(4)

a

to

make

plan

to

all

SU

manage

cells
high

temperatures for patients on psychotropic medication.
DONE, this the 29th day of May, 2020.
/s/ Myron H. Thompson
UNITED STATES DISTRICT JUDGE
84