Photo Credit: Marc Goldberg, Tel Aviv Schizophrenia, Marc’s Words
By: Lisa K. Cagle
Associate Editor, American Journal of Trial Advocacy
Incarceration in the United States has been on the rise for decades,[1] causing the U.S. to have the highest incarceration rate in the world.[2] According to a study by the Department of Justice, more than half of these inmates have mental health problems diagnosable under the DSM-IV.[3] Given that 95% of inmates eventually leave prison and return to the general population,[4] the entire population benefits from treating these mental health problems. Furthermore, in 1976, the Supreme Court of the United States recognized the importance of treating prisoners’ medical conditions and declared that deliberate indifference to prisoners’ serious medical needs is a violation of the Eighth Amendment’s prohibition of cruel and unusual punishment.[5] Recently in Braggs v. Dunn,[6] a federal court in Alabama addressed the issue of “inadequate mental-health care in prison facilities.”[7]
Alabama Prison Conditions
In an effort to change the mental health care practices in Alabama Department of Corrections (“ADOC”) facilities, a lawsuit was brought against Dunn, the commissioner of the ADOC.[8] After a seven-week trial, the court concluded that the ADOC’s mental health care program was “woefully inadequate” and violated mentally ill prisoners’ Eighth Amendment rights.[9] The court noted that the ADOC has experienced a “skyrocketing” suicide rate in the previous two years and reached several conclusions as to the probable cause of the increase.[10] The court noted two major underlying factors: (1) severe overcrowding and (2) staff shortages of both correctional officers and mental health professions.[11] The combination of these factors resulted in unsafe conditions and inadequate mental health care for prisoners with mental health issues.[12]
The court found the conditions in ADOC facilities to be unsafe in general, and especially for inmates with mental health problems. In a lengthy opinion, the court detailed the difficulty in preventing violence in overcrowded prisons without adequate staffing by correctional officers.[13] The court even noted that multiple expert witnesses were advised against entering many prison areas because their safety could not be assured, even though accompanied by armed guards.[14] In addition to the overall unsafe conditions in the ADOC facilities, the court was concerned with unsafe conditions that particularly effect inmates with mental health problems.[15] Among these were the accessibility of sharp objects in prison and the tie-off points in rooms meant to house potentially suicidal inmates.[16] As exemplified during the trial, one of the plaintiffs who suffered from severe mental illness was segregated and left alone for days.[17] Despite serious concerns by the plaintiff’s medical professionals, the plaintiff was left alone in a room where he used a tie-off point to hang himself.[18]
To compound the unsafe conditions for inmates with mental health problems, the court found the mental health care provided by ADOC was inadequate.[19] Starting with intake, inmates with serious mental health problems are either not identified at all or identified as having a lesser mental healthcare need than their condition requires.[20] The court found this is largely due to mental health professional understaffing: mental health professionals being forced to evaluate more inmates in less time than required to do an adequate evaluation.[21] The problem persists inside the ADOC facilities among those identified as needing mental health services. Due to understaffing, inadequate cell-side individual counseling sessions lasting one to two minutes are common.[22] The court was especially concerned with the lack of supervision over inmates in segregation, where the conditions create an environment that increases the likelihood that the already mentally unstable inmate will decompensate.[23] The court noted that the majority of recent suicides were among inmates in segregation.[24]Based on these findings of fact, the court held that mentally ill prisoners in ADOC facilities were being denied their Eighth Amendment rights.[25]
Eighth Amendment Violations
To succeed on an Eighth Amendment challenge, based on the Supreme Court’s precedential 1976 decision, the court defined three elements plaintiffs must prove:[26]
1) The plaintiff has serious mental health needs;[27]
2) These needs, if left unattended, “pose[] a substantial risk of serious harm”;[28] and
3) The defendants “acted with deliberate indifference to that risk [of harm].”[29]
The court concluded that each of these elements were met based on its findings of fact. First, the plaintiffs demonstrated serious mental health needs based on their diagnosis such as schizophrenia and bipolar disorder.[30] Second, the court found that the combination of staff shortages and inmate overcrowding created a “substantial risk of serious harm” for prisoners with serious mental health needs.[31] The court identified seven specific areas where the serious harm was evident.[32] Among these, the court was particularly concerned about the ADOC’s practice of putting prisoners with mental illness into segregation without proper supervision or access to psychological treatment.[33]
Finally, the court held that the defendants “acted with deliberate indifference” to the risk that inmates with serious mental health needs were at a “substantial risk of serious harm.”[34] The court referenced documentation of the ADOC’s inadequacies in compliance reviews and audits over several years.[35] Commissioner Dunn was repeatedly told about concerns regarding inadequate mental health staffing and the direct correlation to inadequate mental health care.[36] The Commissioner was also notified of problems involving identifying serious mental health concerns and the availability of sharp objects and tie-off points to mentally unstable inmates.[37] Yet, the ADOC disregarded these notices and allowed the “inadequacies [to] persist[] for years and years.”[38] Based on the courts conclusion that each of the requisite elements were met, the court held that the ADOC was “violating the Eighth Amendment rights of the . . . [inmates] with serious mental-health needs . . .[,]” as a result of “persistent and severe shortages of mental-health staff and correctional staff, combined with chronic and significant overcrowding . . . .”[39]
[1] Josiah D. Rich et al, Medicine and the Epidemic of Incarceration in the United States, 364 New Eng. J. Med. 2081, 2081 (2011), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3154686/.
[2] Josiah D. Rich et al, How Health Care Reform can Transform the Health of Criminal Justice-Involved Individuals, 33:3 Health Aff. 462, 462 (2014), http://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2013.1133.
[3] Doris J. James & Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates, Bureau of Justice Statistics (Dec. 14, 2006), https://www.bjs.gov/content/pub/pdf/mhppji.pdf.
[4] Rich, supra note 1, at 463.
[5] Estelle v. Gamble, 429 U.S. 97, 104 (1976).
[6]No. 2:14cv601-MHT, 2017 WL 2773833 (M.D. Ala. June 27, 2017).
[7] Braggs, 2017 WL 2773833, at *1.
[8] Id. at *1.
[9] Id. at *6.
[10] Id. at *51.
[11] Id. at *68.
[12] Id.
[13] Braggs, 2017 WL 2773833, at *17.
[14] Id. at *16.
[15] Id. at *31-32.
[16] Id. at *32.
[17] Id. at *6.
[18] Id.
[19] Braggs, 2017 WL 2773833, at *11.
[20] Id. at *18.
[21] Id. at *18-19.
[22] Id. at *50.
[23] Id. at *47.
[24] Id. at *51.
[25] Braggs, 2017 WL 2773833, at *68.
[26] See generally Estelle v. Gamble, 429 U.S. 97 (1976) (outlining elements that a plaintiff must meet).
[27] Braggs, 2017 WL 2773833, at *9.
[28] Id. at *10.
[29] Id. at *55.
[30] Id. at *10.
[31] Id. at *11.
[32] Id. at *11.
[33] Braggs, 2017 WL 2773833, at *50-51.
[34] Id. at *55.
[35] Id. at *57.
[36] Id.
[37] Id. at *57-58.
[38] Id. at *61.
[39] Braggs, 2017 WL 2773833, at *68.
American Journal of Trial Advocacy 