Skip navigation

Alabama Mental Health Suit, Expert Report, 2002

Download original document:
Brief thumbnail
This text is machine-read, and may contain errors. Check the original document to verify accuracy.
December 12, 2003
When the Alabama Department of Corrections (ADOC) was under litigation from 1992
to 2000 regarding the provision of mental health services, there was concern that the
mental health delivery system was less than adequate in addressing the needs of the
inmates. Since 2000, the ADOC has demonstrated a total commitment to developing a
quality mental health system. The progress the ADOC has achieved in three years is
remarkable. Wardens, security supervisors, correctional officers, and inmates alike have
acknowledged that the improved mental health system has reduced disruptions in the
institutions previously experienced due to mental health crises. The need for suicide
watches has dramatically decreased and administrative segregation units are calmer
placements. The increased collaboration between security and treatment staffs has been a
welcomed development.
While the Bradley v. Haley lawsuit and the agreement that resolved the litigation applied
only to male inmates, the Laube v. Haley case, initiated in 2002, addresses mental health
services for female inmates. Consideration has been given to resolving the female inmate
mental health issues using the standards and criteria of the Bradley Settlement Agreement.
During the first six months of 2000, the ADOC and Southern Poverty Law Center brought in
experts to review the services provided inmates with serious mental illness. Expert reports
were written and depositions were conducted in preparation for a trial. In August of 2000,
the ADOC and Southern Poverty agreed to resolve the issues through a settlement agreement.
On August 8, 2000, two mental health experts hired by Southern Poverty Law Center and the
psychiatric expert hired by the ADOC finalized the Bradley v. Haley Agreement of Experts.
This document defined critical aspects of mental health care; established standards for mental
heath services; established the various levels of mental health services required; established
mental health staffing ratios; proposed options for the development of mental health units at
various institutions; determined the mental health policies and procedures for development
and implementation; and established requirements for correctional officer training in mental
health issues. The Agreement of Experts established a blueprint for the development of the
ADOC mental health delivery system.
On September 28, 2000, the Bradley Settlement Agreement was signed. The Agreement of
Experts became central to the agreement by establishing the standards and requirements of
an acceptable mental health system. The agreement established deadlines for completion of
specific tasks and established a consultant/oversight function. Jane Haddad, Psy.D., a
former expert in the case for Southern Poverty Law Center, was identified to provide

Page 2
technical assistance to the ADOC in achieving the required changes, review the mental
health services at each institution, and review quarterly data related to the provision of
mental health services. Based on these activities, Dr. Haddad was to submit a report to the
Court in June of 2003 indicating the level of compliance the ADOC had achieved with the
settlement agreement.
Since the Bradley Settlement Agreement has been initiated, two amendments have been
added. The first extended the agreement and deadlines for completion of specific tasks
by three months to accommodate a delay in the change in contractors for the ADOC
medical and mental health services. The second amendment in August of 2003 extended
the Bradley Settlement Agreement until December 31, 2004. The ADOC requested this
extension due to delays in the construction and implementation of a new mental health
facility. At this time, the ADOC is expected to achieve compliance with the Bradley
Settlement Agreement before December 31, 2004.
Improvements During the Consultant Phase:
During the first year of the Bradley Settlement Agreement, the mental health contractor,
Mental Health Management (MHM), focused on recruitment to substantially increase the
mental health staff. Prior to the agreement, less than 30 mental health professionals
provided services for inmates with serious mental illness within a system of 20,000. The
settlement agreement required an increase to 103 mental health staff. Specifics regarding
the increased staffing will be discussed in the section: Staff Resources for Mental Health
The initial focus for the ADOC in addressing the settlement agreement was determining
where mental health units would be located and what renovations would be required to
accommodate the changes. Numerous tours and discussions ensued between the
consultant, the ADOC Central Office staff, and the Wardens of various institutions. To
ensure that all stakeholders had a common understanding of the issues, the wardens,
deputy wardens, security supervisors, and current mental health staff at institutions where
mental health units were to be located participated in a two-day workshop covering the
principles and expectations of the Bradley Settlement Agreement. These sessions were
critical in achieving consensus about the goals of the effort and in addressing the many
questions about the “cultural shift” that needed to occur.
At the same time as decisions were being made about the location of the mental health
units, the consultant and the ADOC Director of Treatment collaborated in the
development of mental health polices and procedures that were consistent with Bradley
standards and the standards of the National Commission on Correctional Health Care
(NCCHC). Accreditation by NCCHC was not a requirement of the settlement agreement,
but compliance with NCCHC standards was mandated. After the completion of 35
mental health policies and procedures and the forms required to implement the
procedures, drafts of the documents were submitted to all wardens and mental health staff
for comment. When the policies and procedures were finalized, the ADOC made the

Page 3
forward thinking decision to establish the policies and procedures as ADOC
administrative regulations. All institutions are required to comply with the system-wide
guidelines and are not permitted to adopt institution-specific procedures that are
inconsistent with the administrative regulations. Also, if the ADOC mental health
contractor should change, the requirements of the administrative regulations remain. The
ADOC now has its own mental health delivery system, policies and procedures, and
forms. Any contractor for mental health services will be required to implement the
established system.
The new administrative regulations addressed prior practices that had been repeatedly
challenged. Inmates are no longer permitted to remain nude or sleep on a black mat for
extended periods of time as part of suicide precautions. “Safe” crisis cells, suicide
resistant tunics and blankets, beds raised from the floor, and transfer to a mental health
unit if an inmate has not stabilized within 72 hours are now standard practice. Inmate
transfers for mental health reasons receive priority and are based on clinical decisions of
the mental health staff, rather than determinations by security and/or administrative staff.
When an inmate with a serious mental illness receives a disciplinary report, consult with
the mental health staff is required prior to the disciplinary hearing.
Also, during the first year of the agreement, required training programs were developed.
Each correctional officer participates in six hours of training related to mental health
issues. In particular, issues related to the treatment and management of inmates with
serious mental illness are part of the ADOC Basic Training. A two-day Specialized
Mental Health Training was developed for the more intensive training of mental health,
medical, and security staffs assigned to mental health units, segregation units, and
infirmaries where crisis cells are located. Finally, the mental health component was
developed for the annual Advanced Training required for all ADOC staff. This four to
six hour training has been revised and enhanced each year to ensure that the training
provides pragmatic, job-specific information that the staff can appreciate and use.
According to reports by the inmates and correctional officers, the mental health training
has had a positive impact. Officers now have the skills to identify and refer emerging
mental health problems to the mental health staff. In 2001, the consultant provided the
two-day Specialized Mental Health Training for all ADOC wardens, deputy wardens, and
security supervisors. Similar to the training provided to the wardens and other
administrative staff of the institutions housing mental health units, the training of
management and supervisory staff at all institutions provided an opportunity for
consensus building and for addressing the many questions related to the expansion of
mental health services.
The final project embarked upon during the first year of the Bradley Settlement
Agreement was the “coding” of each inmate according to potential mental health needs.
Inmates with serious mental illness, as defined in the Agreement of Experts, are coded
SMI; inmates with a history of expressive violence, as defined by NCCHC, toward

Page 4
themselves or other are coded HARM; inmates with a history of mental health treatment
but no longer requiring services are coded HIST; and inmates with no identified mental
health problems are coded NONE. Initiating mental health coding at the ADOC
reception center was a relatively easy task. However, coding more than 20,000 inmates
already in the system was a major challenge. Coding of these inmates was completed
through interview and record review. As of September 30, 2003, 98% of all inmates have
been coded. The majority of inmates not coded were still in the reception process. The
coding has facilitated the identification of inmates with mental health issues during
intra-system transfers and/or when assigned to segregation.
Physical Resources for Mental Health Services:
Prior to the Bradley Settlement Agreement, the ADOC had 18 single cells at Kilby
Correctional Facility, which served as the intensive mental health treatment unit for male
inmates. The mental health unit had a very small nursing station and no treatment area
other than the day room. The ADOC also had one mental health dormitory of 20 beds at
Kilby Correctional Facility, 24 single cells at Donaldson Correctional Facility, and
dormitories with a total of 200 beds at Bullock Correctional Facility for inmates requiring
long-term treatment for serious mental illness. None of the institutions had adequate
treatment areas nor mental health office space.
The Kilby mental health unit did not have adequate beds to address acute episodes of mental
illness, particularly since admission to the state hospital, Taylor Hardin, was significantly
delayed except for inmates at “end of sentence.” Inmates no longer requiring treatment for
acute conditions, but requiring single cell placement were often maintained on the Kilby
mental health unit because there were no long-term mental health single cells other than the
24 cells at Donaldson.
The ADOC demonstrated a significant commitment to expanding mental health unit
capacity. All of the cells on the mental health unit at Kilby were renovated to create
“safe” cells. A nursing station, treatment room, and additional office space were
developed. The 20-bed dormitory for long-term care at Kilby was closed, since the
potential to develop adequate treatment space was limited.
The most significant improvement in physical resources has been the opening of three
mental health units at Donaldson in November of 2001. These units provide 48 single
cells and 40 cells in which one or two inmates may be housed. While the majority of the
Donaldson cells are designated for long-term mental health care, 12 cells have been
designated as “infirmary” cells for the treatment of acute episodes of mental illness. The
ADOC has made numerous renovations to the Donldson units to ensure their
appropriateness for mental health treatment. A nursing station and treatment rooms were
provided on two of the units. The units were air conditioned to address the risk to inmates
prescribed psychotropic medications during times and seasons of extreme heat. Three
mental health offices were constructed in the health care unit for mental health staff and a
room near the three mental health units was renovated for a medication room. Finally, a

Page 5
new Programs Building was constructed to provide treatment rooms and adequate office
space for mental health staff. Donaldson is currently in the process of fencing a
courtyard area to ensure that inmates assigned to the mental health units have adequate
access to outdoor recreation.
While the Bradley Agreement required renovations at Bullock Correctional Facility to
increase treatment and office space for the large mental health dormitories, ADOC chose
to build a new mental health facility at Bullock. Currently, the Bullock mental health
unit is under construction with occupancy expected during the first quarter of 2004. The
unit was designed to provide 200 dormitory beds, “state of the art” treatment areas,
sufficient offices for mental health staff, and a 30-cell mental health unit for the intensive
treatment of inmates experiencing acute episodes of mental illness. When the Bullock
intensive stabilization unit is operational, the mental health unit at Kilby will no longer be
required to operate in such a capacity.
While the renovation and construction of mental health units received priority, other
ADOC male institutions also required physical modifications to ensure adequate
treatment and office space for outpatient services. All crisis cells in the system were
required to comply with standards established by ADOC for “safe” cells. Providing
additional treatment and office space within the very over-crowded ADOC system was a
major challenge. As of September 30, 2003, adequate space has been established at all
but two institutions. The mental health offices have computer lines that are linked with
the ADOC tracking system to facilitate mental health staff access to information. While
all mental health programs have at least one computer, the ADOC has committed to
significantly increasing the number of computers during 2004.
Staff Resources for Mental Health Services:
As previously noted, less than 30 mental health staff provided services to male inmates
with serious mental illness prior to the Bradley Agreement. Less than three psychiatrists
had been available for the psychiatric follow-up on all 20,000 ADOC inmates. The
Bradley Agreement required staffing of 103 mental health staff to include 11 psychiatrists
of which 3 could be nurse practitioners and 24-hour nursing coverage for the mental
health units that provided intensive mental health treatment.
The Bradley staffing levels do not include the ADOC psychology staff. The ADOC
psychology staff, who are state employees, conduct reception evaluation, conduct ADOC
workshops, and provide follow-up for inmates who do not have a serious mental illness.
The mental health administrative regulations define the specific responsibilities of the
ADOC psychology staff and the contractor’s mental health staff. While interface between
the two staffs initially experienced some difficulties, collaborative and supportive
relationships have developed during the last three years.
Recruiting for 70 new mental health staff positions was challenging, particularly for
psychiatric and mental health nurse positions. As expected, there was also a great deal of

Page 6
turnover in new staff as some learned that correctional mental health care was not for
them. Fortunately, mental health staffing has now stabilized. As of September 30, 2003,
98% of the psychiatric hours were provided; 106% of the licensed psychologist hours
were provided; 100% of the mental health professional hours were provided; 2 of the 3
supervising mental health nurse positions were filled; 99% of the mental health nursing
hours were provided; 73% of the activities technician hours were provided; and 120% on
the mental health clerk hours were provided. The new contract for mental health services
that became effective November 3, 2003, increased mental health staffing levels at a few
institutions based on increasing needs.
All mental health staff are required to attend Specialized Mental Health Training.
Typically, mental health staff complete this requirement within two months of being
hired. Mental health nurses are required to complete an additional five days of jobspecific training and activities technicians are required to complete an additional eight
days of job-specific training that includes practice in conducting psychoeducational
groups. While there was a significant delay in developing the modules for the jobspecific training, excellent training modules were developed by September of 2003. All
presently employed mental health nurses and activities technicians have participated in
the required training.
Outcomes of the Improved ADOC Mental Health System for Male Inmates:
While increases in the mental health physical plant and staff resources were essential to
improve ADOC mental health services, outcomes are the best indication of
improvements. The current mental health delivery system reflects the following:
1 Inmates received by ADOC are screened for mental health issues immediately
upon arrival.
2 Inmates receive an initial psychiatric evaluation within five days of admission to
the ADOC if there is a history of mental health treatment or the inmate was
prescribed a psychotropic medication. Inmates receive an immediate psychiatric
evaluation if the screening nurse judges that such is clinically indicated based on
the inmate’s history and/or presentation.
3 Inmates are coded to reflect their potential need for mental health treatment and
mental health codes are considered in placement and disciplinary decisions.
4 Inmates requiring crisis intervention are placed in “safe” cells and receive daily
mental health follow-up. If a crisis has not resolved within 72 hours, the inmate
is considered for transfer to a mental health unit.
5 Inmates placed in segregation units receive cell-to-cell rounds weekly to ensure
access to mental health services in addition to the twice a week segregation
rounds conducted by the ADOC psychology staff.
6 The availability of psychotropic medication has improved. Nursing staff monitor
medication compliance and ensure the provision of laboratory testing required by
the use of some psychotropic medications.
7 Inmates with serious mental illness who are maintained with outpatient services
are seen by mental health professionals monthly and by a psychiatrist or nurse

Page 7


practitioner no less than every 90 days.
Intensive psychiatric stabilization treatment includes daily psychiatric follow-up
and 24-hour nursing coverage.
Inmates who require long-term treatment and support for chronic mental illness
receive services in adequately staffed Residential Treatment Units. The opening
of Residential Treatment Units at Donaldson for inmates requiring single cell
placement has been praiseworthy. The improvements in the functioning of the
inmates and the opportunities afforded them, while on the unit, have been
Training of correctional officers has increased their sensitivity to mental health
issues and appreciation for the role of treatment staff in institutional operations.
Mental health staff have developed an effective quality improvement program that
identifies and addresses system-wide and institutional-specific areas for

It would be misleading to assert that the “outcomes” listed above are consistently
achieved. Changes in mental health staff can compromise services and some institutions
have developed more consistent services than others, however, overall compliance has
been acceptable.
Challenges Remaining for ADOC Mental Health Services for Male Inmates:
While full implementation of the Bullock Correctional Facility program was the major
reason for the extension of the Bradley Agreement, the additional time will allow for the
following developments:
1 Individualized treatment plans can be consistently developed and reviewed by a
multidisciplinary team. Previously, limited psychiatric coverage at some
institutions providing outpatient services resulted in the psychiatrist signing the
treatment plan without participating in the planning process.
2 Refinement of the inmate mental health codes by a multidisciplinary treatment
team to ensure the accuracy of the codes.
3 Increased security coverage on mental health units permiting full implementation
of treatment and programming services. The impact of the number of correctional
officer vacancies at the various ADOC institutions was markedly increased by the
number of correctional officers called to active duty with the armed forces.
4 Completion of remaining renovations for outpatient mental health office space
and crisis cells.
5 Provision for an adequate number of computers for mental health staff.
6 Ensuring that the most appropriate psychotropic medication has been prescribed.
The previous lack of a pharmacy report on psychotropic medications precluded an
accurate assessment of prescribing practices. Previous reviews of psychotropic
medications suggested a reliance on older anti-psychotic medications,
particularly decanoate medications.
7 Ensuring that documentation of mental health services consistently reflects
continuity of care. While the mental health documentation has improved during

Page 8
the last two years, there is always room for improvements in documentation.
Challenges Remaining for ADOC Mental Health Services for Female Inmates:
As previously noted, the Bradley Settlement Agreement applies only to male inmates,
however, since implementation of the agreement, the ADOC has attempted to include
Tutwiler, the female institution, into the Bradley mandates. The mental health/treatment
administrative regulations apply to all ADOC inmates. Female inmates receive mental
health codes and staff attempt to provide services consistent with the administrative
regulations. Improved services for female inmates appeared compromised by inadequate
mental health staffing; the lack of adequate mental health office space; and the lack of
physical plant resources for intensive and long-term mental health services.
Recently, mental health staffing for Tutwiler was significantly increased and adequate
mental health staff offices were provided. The provision of mental health services for
female inmates should improve once the new mental health staff develops an efficient
service delivery system and the ADOC determines how appropriate housing for intensive
and long-term mental health treatment will be met.
It has been a privilege to provide consulting and oversight for the Bradley Settlement
Agreement since October of 2000. The improvements in mental health services have
been impressive. Even in an environment of scarce resources and limited funding,
positive changes have been observed in the functioning of individual inmates as well as
the treatment opportunities offered throughout the ADOC system.
These positive changes are attributed to the support of the previous Commissioner,
Michael Haley, and the current Commissioner, Donal Campbell. Commissioner
Campbell has been steadfast in ensuring that all ADOC and contracted staffs understand
that the provision of appropriate mental health care is a priority. Finally, the “hands-on”
support by Greg Lovelace, Deputy Commissioner of Operations, and Dr. Ronald
Cavanaugh, Director of Treatment, have been essential in effecting the necessary
changes. The appreciation of the wardens and security supervisors for the positive
impact of improved mental health services on institutional management should facilitate
the maintenance of the mental health delivery system long after compliance with the
Bradley Settlement Agreement is achieved.
Jane Haddad, PsyD
ADOC Mental Health Contract Monitor