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XI. CASE STUDY: ALABAMA, A SYSTEM IN CRISIS

In 1990, a psychologist at West Jefferson Correctional Facility, Alabama, wrote to the Director of Mental Health Treatment for the Alabama Department of Corrections (ADOC) about the inability to get prisoners transferred to the system’s acute care facility:

We have six men who have been ordered to Kilby Correctional Facility Psychiatric Ward. One was ordered December 6, 1989, one on December 20, 1989, two on December 29, 1989 and one on January 5, 1990. We are told that Kilby Correctional Facility has no beds.⁴⁶⁶

A month later, the Director of Mental Health Treatment informed the ADOC’s Associate Commissioner that “the physical facilities for Mental Health In-Patient Care at Kilby are totally inadequate.” At the time, Kilby had only eighteen beds to deal with all the acute psychiatric patients in Alabama’s prisons. Based on Department of Justice estimates of the numbers of prisoners in need of in-patient psychiatric care, the Director recommended two hundred more beds be brought on-line by 1995.⁴⁶⁷

The beds were not created. In 1992, two years after this recommendation, the Director of Mental Health Treatment for MBM — the organization subcontracted to provide mental health care at the Kilby facility — informed the Department of Corrections that because of chronic overcrowding and long waiting lists, “we can, therefore, not accept inmates for admission to Mental Health unless the transferring facility accepts, in return, inmates who have been stabilized and released from inpatient status. That is, man for man swaps must be made.”⁴⁶⁸

By the early 1990s, the scale of Alabama’s failings on mental health services were obvious to all who cared to look. In 1992, the Bradley v. Harrelson (the case name subsequently changed to Bradley v. Hightower)⁴⁶⁹lawsuit was filed against the ADOC alleging across-the-board failings in the provision of mental health services. Despite the filing of the lawsuit, conditions did not improve.

The year following, in June 1993, the mental health staff at Staton Correctional Facility informed the ADOC that paranoid, self-mutilating prisoners were being held in the prison’s isolation cells because of a lack of mental health beds. They also alleged, in an email, that:

Questcare, the medical contractor for Department of Corrections, has chosen to restrict available medications which are prescribed by the treating psychiatrist. These include major tranquilizers and antidepressants which are essential to treating a number of inmates at all institutions. Dr. Margaret Bok, former psychiatrist at Staton, resigned due in part to her frustration treating inmates without having these medications to prescribe.⁴⁷⁰

The Bradley lawsuit took five years before any judicial ruling on the merits. Finally, in April 1997, the court found that the above-mentioned swap process delayed necessary transfers and kept acutely mentally ill prisoners separated from urgently needed mental health care.⁴⁷¹ There were also long delays in removing prisoners from Kilby to Taylor Hardin, the state’s secure psychiatric medical facility. Surveying the history of delayed treatment, the court wrote that:

In 1989, the average delay from the filing of the petition for commitment of the inmate to actual transfer of the inmate was 89 days. In 1992, it was 72 days. In 1993, the delay was over six months. In 1994, the delay was still 90 days. During the period time between arrival at Kilby and transfer to Taylor Hardin, inmates were housed in single cells on either the P-1 ward, C-Block, or the West Ward isolation cells. During this period of time, inmates so confined were suffering substantial harm.⁴⁷²

A federal court ordered the ADOC to set in place a plan to remedy the constitutional violations in the provision of mental health services. Yet, change was slow in coming, and the plaintiffs continued to argue for further court interventions.

In 2001, when three correctional mental health experts toured the Alabama prison system on behalf of the plaintiffs in connection with the ongoing Bradley litigation, they found mental health services still in crisis. It was what one of the experts, Professor Fred Cohen, has scathingly termed a “primitive” mental health system presided over by a director who had had his license suspended in two states, and with only three psychiatrists for a prison population of over twenty thousand.⁴⁷³

The final expert report is a detailed and damning assessment of mental health services — or the lack thereof — in the Alabama prison system.⁴⁷⁴ It concludes the ADOC’s:

system for identifying, housing, and treating inmates with serious mental illness is grossly inadequate and riddled with systemic deficiencies. This is not to say that all aspects of the system and every facility are equally deficient…. Pockets of minimal acceptability, however, cannot lift an entire system to the level of acceptability.⁴⁷⁵

The experts found that Alabama prison system’s “clinical staff is hopelessly thin and often under-qualified.”⁴⁷⁶ The “seriously deficient” mental health staffing levels:

do not permit the provision of timely or minimally adequate treatment of inmates with mental illness. Without sufficient staff, inmates identified with mental illness receive grossly inadequate care and follow-up, while other inmates with mental illness remain unidentified…. [Because of inadequate mental health staffing] therapeutic programming is either severely limited or non-existent.⁴⁷⁷

In the ninety-page document, the experts provide extensive documentation of numerous problems plaguing the system. Their report suggests that just about every problem that might be encountered in a prison mental health system exists in Alabama. We quote below from the report’s catalogue of practices that “result in the prolonged and needless suffering of may inmates with serious mental illness:”⁴⁷⁸

• There is no practical access to hospital-level treatment, and the care that is given this designation at Kilby Mental Health Unit does not approximate hospital care.⁴⁷⁹

• Inmates with serious mental illness report that they frequently must violate rules, hurt themselves or cause property damage to gain the attention of staff. Often even this destructive behavior does not eventuate in treatment; only further disciplinary action and segregation result.

• The medical records do not reflect adequate treatment planning or interventions and there is simply no way to determine continuity of care.

• Acutely psychotic inmates are locked-down for long periods of time with little or no treatment….

• Medications are administered in a dangerous and unprofessional manner.

• Therapeutic programs and counseling are wholly inadequate. Some claims as to providing psychotherapy, both in terms of frequency and what this clinical activity entails, are transparently false.⁴⁸⁰

• Conditions of confinement in some areas housing inmates experiencing serious mental illness are totally unfit for these very vulnerable inmates.

• Based on inmate reports and medical record documentation, some mental health staff have demonstrated a general distrust of and contempt for individual inmate-patients.

• The only treatment consistently available is psychotropic medication, but the medication is administered improperly; required monitoring often if not done; and medication is sometimes prescribed without the physician ever seeing the inmate. Medication is not supplemented anywhere we visited by adequate therapy or therapeutic programming….

• There is little or no evidence of effective training of staff on the rudiments of mental illness and medication.

“Alabama is the worst system I’ve seen, or ever hope to see,” Fred Cohen told Human Rights Watch. The prisoners:

received unbelievably poor levels of care. In one facility — a residential treatment unit — the water was overflowing. Inmates were verbally harassed, physically harassed. They were pulled out of bed and knocked about by correctional officers…. There were a few correctional officers working in serious mentally ill units who were characterized as particularly brutal. I cross-referenced these allegations. They would just beat these guys. I’d never seen anything like this.⁴⁸¹

Before the courts could issue a further ruling, Alabama agreed to settle the case and expand its mental health services.

Human Rights Watch attempted to contact the Alabama Department of Corrections on several occasions over a one-year period to ask for their perspective on these findings. The Department repeatedly refused to respond. Finally, the mental health director informed Human Rights watch that the ADOC Commissioner had sent a letter to his staff instructing them not to convey any information to Human Rights Watch.⁴⁸²

Mental health care is also inadequate for incarcerated women in Alabama. In 2002, prisoners at Tutwiler, the state's only prison for women, filed a lawsuit charging that overcrowding of prisoner dorms and significant understaffing of security guards in the Alabama state prison system violated prisoners’ Eighth Amendment rights.⁴⁸³ Tutwiler, built in 1942 to house 364 prisoners, was home to approximately 1017 women at the time of the lawsuit.⁴⁸⁴ Chief among the prisoners’ complaints was the substandard treatment of mentally ill prisoners.

Due to overcrowding at Tutwiler, many mentally ill women in need of supportive living environments are mixed into the general population.⁴⁸⁵ According to the complaint prepared by attorneys from the Southern Center for Human Rights, if a mentally ill prisoner is not considered to be a threat to herself and is not experiencing acute mental health problems, she is placed in the general population regardless of the severity of her illness. Unstable prisoners are “left to roam around the large dormitories talking to themselves and acting in a bizarre and often threatening manner.”⁴⁸⁶

In 2002, Cheryl Wills, M.D., toured the Tutwiler facilities as part of a report prepared for the plaintiff prisoners. In her report, Dr. Wills recounts interviews with several prisoners who emphasized the insufficiency of medical and mental health care at the facility. According to the prisoners she interviewed:

• There is no residential mental health program for the prisoners at Tutwiler.

• Psychiatric services are not easily accessible for prisoners that are not acutely ill.

• The easiest way to receive mental health care was to harm oneself, and that strategy was not always successful.

• Prisoners were frequently disciplined for exhibiting symptoms of their mental illness.

All prisoners interviewed by Dr. Wills agreed that the facility was dangerously overcrowded.⁴⁸⁷

After evaluating the plaintiffs’ claims of overcrowding, understaffing, and substandard medical and mental health care, federal district judge Myron Thompson held that “these unsafe conditions have resulted in harm and the threat of harm to individual inmates…[and] are essentially a time bomb ready to explode facility-wide at any unexpected moment in the near future.”⁴⁸⁸ He found that housing of mentally ill prisoners in the general population was dangerous not only to other prisoners, but to the mentally ill prisoners themselves, who were “vulnerable to control and attack at the hands of aggressive inmates.”⁴⁸⁹

The Tutwiler Prison Plan developed by the defendants, Governor Riley, Commissioner Campbell, and Warden Deese, includes plans to speed up the parole process for non-violent offenders at Tutwiler, and reduce the number of Tutwiler prisoners.⁴⁹⁰ The plan does not, however, address increased corrections or health care staffing, improved delivery of mental or medical health care services, or the development of more specialized living facilities for seriously mentally ill prisoners.