Federal Appeals Court Finds Constitutionally Inadequate Mental Health Care in Alabama Prisons

The U.S. Court of Appeals for the Eleventh Circuit on Wednesday affirmed a lower court's ruling that Alabama's mental health care for people in state prisons is constitutionally inadequate and rejected nearly all of the State's objections to court orders requiring improvements in care.

The decision comes in a lawsuit filed by Alabama prisoners with serious mental illness and the Alabama Disability Advocacy Program, who alleged that the Alabama Department of Corrections fails to provide adequate mental health care to people in state prisons.

After hearing seven weeks of testimony and reviewing thousands of pages of documentary evidence, the federal district court identified "serious deficiencies" in ADOC's mental health care, including the failure to identify prisoners with serious health needs and inadequate treatment for suicidal prisoners.

Concluding that mental health care in Alabama prisons is "horrendously inadequate," the court determined that ADOC's "deliberate indifference" to the serious mental health care needs of people in its prisons constituted cruel and unusual punishment in violation of the Eighth Amendment. It issued comprehensive, system-wide relief to remedy these constitutional deprivations.

That ruling was in 2017, nearly a decade ago. But rather than implement remedies, Alabama has spent millions of dollars paying lawyers to fight this decision in court. ADOC appealed to the Eleventh Circuit, arguing that the district court's findings were wrong and its orders were obsolete and overbroad.

The Eleventh Circuit flatly rejected ADOC's attacks on the district court's "thorough and commendable" determination that ADOC's mental health care system violates the Eighth Amendment.

"Systemic and gross deficiencies" have persisted "for years and years," the court wrote, leading to a skyrocketing suicide rates among incarcerated people. Indeed, it found, "[d]uring one 15-month period of this litigation, 15 Alabama inmates killed themselves."

ADOC's failures started "at the door," the court wrote, starting with severe and chronic overcrowding. Severe understaffing of mental health providers led to the failure to identify inmates with serious mental-health needs. As a result, ADOC has "one of the lowest purported percentages in the country of mentally ill prisoners, while simultaneously having a high number of suicides." Further, the court found, "a combination of inadequate treatment planning, psychotherapy, inpatient care, and crisis care rendered treatment in the prisons wholly inadequate."

When the system is viewed as a whole, we detect no error-factual or legal-in the district court's finding of deliberate indifference.

ADOC argued the district court's finding was invalidated by changes in circumstances. But the appeals court found that ADOC had made no significant changes. Instead, ADOC has demonstrated "a long history of failing to comply with the remedial orders in this case" and making misrepresentations to the court.

Indeed, the court upheld the district court's order that restrictive housing cells be cleaned between occupants because the cells "were often filled with the smell of burning paper and urine, and extremely dirty with what appears to be dried excrement on the walls and floors, contributing to a heightened risk of decompensation for mentally ill prisoners and a heightened risk of developing serious mental health needs for those who were initially healthy." The order was necessary, the court found, because ADOC's statements that it was cleaning the cells were not credible.

The appeals court denied all but two ADOC objections to remedies, allowing that ADOC is not constitutionally required to suicide-proof every cell or to fill staffing positions that are unrelated to the provision of mental health care.

All of the other remedial provisions were upheld, including restrictions on the placement of people with serious mental illness in restrictive housing.

The court partially excepted Tutwiler Prison for Women, where the last suicide occurred in 2004, from remedial provisions about monitoring, mental health care in segregation, the number of crisis cells, residential treatment units, and suicide-watch placements.

But it rejected ADOC's challenges to external monitoring, noting that ADOC admitted it lacked the capacity to monitor its own compliance with the court's orders and the external monitoring team was ordered to train an ADOC team so it could take over monitoring. Further, the court agreed that ADOC's previous failure to comply with interim remedial orders suggested it was unable "to take" effective "remedial steps absent court intervention."

"Sometimes drastic remedies are the least intrusive and yet necessary means of correcting an Eighth Amendment violation," the appellate court concluded. "That is the case here."