September 30, 1997

TABLE OF CONTENTS

    .@.1 1.     Introduction

    .@.2 2.     Bibliography of Professional Standards and Other Sources

    .@.3 3.     General Principles

a.
Mental health care must be available to all inmates who need it.
1

    b.

Mental health care provided to inmates must be equivalent to care

available in community .
1

    c.

Mental Health decision-makers must be independent of

other prison officials.
2

    .@.4 4.

Preliminary Mental Health Screening of Incoming Prisoners and Referrals forTreatment
2

    a.

Correctional facilities must have a system to screen incoming

inmates to identify those with mental illness
2

    b.

Contents of the Preliminary Mental Health Screening
4

    c.

Preliminary screenings must be conducted in a

confidential atmosphere
5

    d.

Screeners need training in mental illnesses.
6

    .@.5 5.     Mental Health Assessment of all Prisoners

    a.

All newly committed inmates should receive a detailed
6

mental health evaluation shortly after admission.

         b.
Contents of Mental Health Assessment
7

    .@.6 6.

Follow up Referrals from Preliminary Screening and Mental Health Assessment
8

    a.

Inmates should receive a thorough psychiatric evaluation within

a short period after staff make a referral
8

    .@.7 7.     Monitoring and Diagnosis of Inmates with Mental Illness

    a.

Every correctional facility must have procedures for custody
staff and inmates to refer inmates needing mental health

treatment or evaluation.
9

    .@.8 8.

Mental Health Treatment Modalities
10

    a.

Correctional facilities must provide a range of treatment

modalities to inmates with mental disabilities.
10

    b.

Treatment must consist of more than just medication
12

    c.

Each inmate must have an individualized treatment plan
12

    d.

Prisons must have written policies to assure timely delivery

of needed mental health services
13

    e.

Mental health care should be available on a 24-hour basis.
14

    f.

Inmates must be provided with information about mental health

services in a language they can understand
14

    .@.9 9.     Medication

    a.

Psychotropic medication must be prescribed only by a psychiatrist

and in accordance with contemporary medical standards
15

    b.

Psychiatrists or physicians should monitor all inmates

on psychotropic medications.
15

    c.

A psychiatrist must re-evaluate prescriptions before renewal
16

d.
The formulary should contain a range of psychotropic medications
16

e.
Prisoners must receive prescribed medications without interruption
17

    f.

A system must be in place for the involuntary administration

of psychiatric medications in appropriate circumstances
17

g.
Prisoners with serious mental disorders must be transfered to

a hospital or to a specialized unit within the prison system,
18

h.
Inmates may not be transferred to a mental hospital without due process
20

    .@.10 10.     Informed Consent

a.
Patients must be given the information necessary to make an

informed decision about whether to accept a particular treatment.
20

    .@.11 11.     Seclusion and Restraint

a.
Correctional Facilities must have policies and procedures

governing the use of seclusion and restraint
21

b.
Seclusion and restraint may not be used as punishment.
23

    .@.12 12.     Suicide Prevention

a.
Correctional facilities must have a basic program for

        suicidal tendencies

    .@.13 13.     Mental Health Staff

a.
The correctional facility must have sufficient numbers of

        adequate evaluation and treatment consistent with

        contemporary standards of care.

b.
Mental health staff must receive appropriate training,

    .@.14 14.     Training of Custodial Staff

a.
All custodial staff must be trained to recognize signs of

    .@.15 15.     Housing, Segregation, and Discipline

a.
Mental health staff must be allowed to influence cell

b.
Inmates confined to segregation units must be evaluated and

c.
Mental health staff must be consulted about decisions to

    .@.16 16.     Mental Health Records

a.
Mental Health Records must be accurate, complete,

b.    Past psychiatric records must be obtained    
32

c.
Inmate's mental health records must be kept confidential
33

d.
Only a limited number of factors justify breaching a patient's

e.
To preserve confidentiality, mental health records must be kept

f.
Mental health providers should have access to inmates'

g.
Inmates must have access to their own records
36

h.
When an inmate is transferred to another institution,

        continuity of care.

i.
Inmates must give written consent before their records are

a.
Prison mental health services must provide appropriate discharge

    .@.18 18.     Quality Assurance

a.
The correctional mental health system must have a quality assurance

INTRODUCTION:

    There are approximately 1.6 million people incarcerated in prisons or jails in theUnited States, and the number continues to increase each year. Studies indicate that theincidence of mental illness is substantially greater in prison than in the community. At anygiven time at least 7% of all incarcerated individuals suffer from a major mental illness, andan additional 10 to 30% of the prison population is likely to require mental health services atsome point during their incarceration. Despite the great need for mental health treatment incorrectional facilities, however, available services in many, if not most, prisons and jails arewoefully inadequate.

    Since there is little public or political support for quality mental health care foroffenders with mental illness, prisoners are almost entirely dependent on the courts for theprotection of their right to treatment. However, it is often difficult for advocates who are notfamiliar with correctional environments to make an informed assessment of mental healthservices within a particular facility. The constitutional law in this area, although extensive, isoften murky and inconsistent. See "Annotated List Of Cases Relating To Treatment ForPersons With Mental Illness In Prisons And Jails," Center for Public Representation (1997). Moreover, since the Constitution only requires the absolute minimum level of services, anadequate mental health system may well demand something better.

    In an effort to simplify the task of evaluating whether there are deficiencies in mentalhealth care in correctional settings, we have compiled a comprehensive summary of availablestandards, established by professional organizations and accrediting bodies, that set forth thebasic components of an adequate mental health system in a prison or jail. It is our hope thatthe summary can be used by advocates as a check-list to evaluate services to persons withdisabilities in correctional settings. Although each professional organization has its own viewson any particular aspect of mental health care, we have extracted from the professionalstandards an outline of the generally accepted essential components of an adequate correctionalmental health system. We have then annotated each component with references to the relevantprofessional standards. Although the annotations generally quote the exact language of therelevant standard, in order to keep within manageable limits, the complete standard is notalways provided, nor is every relevant standard necessarily listed. We have also omittedcommentary and other supplementary material that appears in the publications of theprofessional organizations containing the standards. We therefore urge advocates to refer tothe standards themselves for citation purposes, and to check for additional information thatmay not be in the summary. Advocates should also keep in mind that many states have theirown statutes and regulations governing some or all aspects of prison mental health care. Thesestatutes and regulations are often modeled on the professional standards.

    Although the professional standards may well exceed the constitutional floor, courtsoften utilize them both to analyze the quality of mental health care and to devise remedies for conditions found to be unlawful. Accordingly, the annotations contain citations to a selectionof cases where the court has ruled that the substance of the standard coincides withconstitutional mandate. The annotations also reference a selection of useful articles from lawreviews or professional journals that bear on the subject.

    We hope that this summary is helpful to advocates working in prisons and jails, and wewelcome questions and comments from all who have the opportunity to use it.

BIBLIOGRAPHY OF PROFESSIONAL STANDARDS AND OTHER SOURCES    

    ABA Criminal Justice Mental Health Standards (American Bar Association 1984)

    ACA Manual of Correctional Standards, ch.26, § 14, reprinted inMedical Care of Prisonersand Detainees app. (Ciba Found. Symposium 16 (n.s.), 1973)

    American Ass'n of Correctional Psychologists, Standards for Psychological Services in AdultJails and Prisons, 7 Crim. Just. & Behav. 81 (1980)

American Correctional Ass'n & Comm'n on Accreditation for Corrections (3rd ed. 1990)

    Standards for Adult Correctional Institutions

    American Psych. Ass'n, General Guidelines for Providers of Psychological Services (1987)

    American Pub. Health Ass'n (1986), Standards for Health Servs. in Correctional Institutions

    American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29 (1989)

    Association of State Correctional Administrators, Policy Guidelines: Health Services, reprintedinMedical Care of Prisoners and Detainees app. (Ciba Found. Symposium 16 (n.s.),1973)

    Fed. Standards for Prisons and Jails (U.S. Dept. of Justice 1980)

    Foundation/Core Standards for Adult Local Detention Facilities (American Correctional Ass'n& Comm'n on Accreditation for Corrections 1989)

    Joint Comm'n on Accreditation of Healthcare Org., 1 1993 Accreditation Manual for MentalHealth, Chemical Dependency, and Mental Retardation/Developmental DisabilitiesServices § FC at 61 (1993) (forensic services)

    National Comm'n on Correctional Health Care, Standards for Health Services in Prisons(1997)

    National Comm'n on Correctional Health Care,

    National Comm'n on Correctional Health Care, Position Statement: Mental Health Services inCorrectional Settings (1992).

    Standard Minimum Rules for the Treatment of Prisoners: Resolution of the First United NationsCongress on the Prevention of Crime and the Treatment of Offenders, E.S.C. Res.663C, U.N. ESCOR, 24th Sess., Supp. No. 1, at 11, U.N. Doc. A/CONF/611(1955), amended by E.S.C. Res. 2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at 35,U.N. Doc. E/5988 (1977)

Arnold on behalf of H.B. v. Lewis, 803 F.Supp. 246 (D.Ariz. 1992)

Austin v. Pennsylvania Dept. of Corrections, 876 F. Supp.. 1437 (E.D. Pa. 1995)

Balla v. Idaho State Bd. of Corrections, 595 F. Supp. 1558 (D. Idaho 1984)

Barnes v. Government of Virgin Islands, 415 F. Supp. 1218 (D.V.I. 1976)

Casey v. Lewis, 834 F.Supp. 1477 (D.Ariz. 1993)

Coleman v. Wilson, 912 F.Supp. 1282 (E.D. Cal. 1995)

Franklin v. District of Columbia, -- F.Supp. --, 1997 WL 194453 (D.D.C. 1997)

French v. Owens, 777 F.2d 1250 (7th Cir. 1985)

Grubbs v. Bradley, 821 F. Supp. 496 (M.D. Tenn. 1993)

Langley v. Coughlin, 715 F.Supp. 522 (S.D.N.Y. 1988), aff'd, 888 F.2d 252 (2d Cir. 1989).

Lightfoot v. Walker, 486 F. Supp. 504, 524-25 (S.D. Ill. 1980)

Madrid v. Gomez, 889 F.Supp. 1146 (N.D. Cal. 1995)

Ruiz v. Estelle, 503 F.Supp. 1265 (S.D. Tex. 1980), aff'd in part and rev'd in part, 679 F.2d1115 (5th Cir. 1982), cert. denied, 460 U.S. 1042 (1983).

    Fred Cohen, Captives' Legal Right to Mental Health Care, 17 Law & Psychol. Rev. 1 (1993)

Fred Cohen & Joel Dvoskin, Inmates With Mental Disorders: A Guide to Law and Practice     (Part I), 16 MENTAL & PHYSICAL DISABILITY L. REP. 339 (1992).

Fred Cohen & Joel Dvoskin, Inmates With Mental Disorders: A Guide to Law and Practice     (Part II), 16 MENTAL & PHYSICAL DISABILITY L. REP. 462 (1992).

    Deborah L. Dennis, The National Work Session: Recommendations for Action, inMentalIllness in America's Prisons 213 (Henry J. Steadman and Joseph J. Cocozza eds.[National Coalition for the Mentally Ill in the Criminal Justice System], 1993)

    James R.P. Ogloff et al., Screening, Assessment, and Identification of Services for Mentally IllOffenders, in Mental Illness in America's Prisons 61 (Henry J. Steadman and Joseph J.Cocozza eds. [National Coalition for the Mentally Ill in the Criminal Justice System],1993)

James R.P. Ogloff, et al., Mental Health Services In Jails And Prisons: Legal, Clinical, And     Policy Issues, 18 Law & Psychol. Rev. 109 Spring 1994

    Marnie E. Rice & Grant T. Harris, Treatment for Prisoners with Mental Disorder, in MentalIllness in America's Prisons 91 (Henry J. Steadman and Joseph J. Cocozza eds.[National Coalition for the Mentally Ill in the Criminal Justice System], 1993)

T. Howard Stone, Therapeutic Implications Of Incarceration For Persons With Severe

1.    Introductory Principles

a.     Mental health care should be available to all inmates who need it.

Standards for Health Servs. in Correctional Institutions., Mental Health Care Services § A, at 27(American Pub. Health Ass'n 1976) ("Principle: Mental health services should be made availableat every correctional institution. Public Health Rationale: Any person should be able to seekmental health care. Moreover, the very fact of incarceration may create or intensify the need formental health services."); Standards for Adult Correctional Institutions. § 3-4331 (AmericanCorrectional Ass'n & Comm'n on Accreditation for Corrections 3rd ed. 1990) (mandatory)("Written policy, procedure, and practice provide for unimpeded access to health care."); ABACriminal Justice Mental Health Standards § 7-2.6(a) (American Bar Association 1984) (postarrestobligations of police and custodial personnel) ("It is the responsibility of custodial officials toensure that mental health and mental retardation services are provided for detainees."); StandardMinimum Rules for the Treatment of Prisoners: Resolution of the First United Nations Congresson the Prevention of Crime and the Treatment of Offenders, E.S.C. Res. 663C, U.N. ESCOR,24th Sess., Supp. No. 1, ¶ 22(1), U.N. Doc. A/CONF/611 (1955), amended by E.S.C. Res.2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977) (medical services)("At every institution there shall be available the services of at least one qualified medical officerwho should have some knowledge of psychiatry. The medical services . . . shall include apsychiatric service for the diagnosis and, in proper cases, the treatment of states of mentalabnormality."); id., ¶ 62 (prisoners under sentence) ("The medical services of the institution shallseek to detect and shall treat any physical or mental illnesses or defects which may hamper aprisoner's rehabilitation. All necessary medical, surgical and psychiatric services shall be providedto that end."); id., ¶ 82(4) (insane and mentally abnormal prisoners) ("The medical or psychiatricservice of the penal institutions shall provide for the psychiatric treatment of all other prisoners[than those removed to mental or specialized institutions] who are in need of such treatment.").

b.     Mental health care available to inmates must be equivalent to that in the community.

National Comm'n on Correctional Health Care, Position Statement: Mental Health Services inCorrectional Settings § 1 (1992) ("All correctional institutions should be required to meetrecognized community standards for mental health services as promoted by standards set byorganizations such as the National Commision on Correctional Health Care, the AmericanPsychiatric Association, and the American Public Health Association"); American PsychiatricAss'n, Principles Governing the Delivery of Psychiatric Services in Lock-Ups, Jails and Prisons,in Psychiatric Services in Jails and Prisons, Task Force Report 29, § B.1.a (1989) ("Thefundamental policy goal should be to provide the same level of mental health services to patientsin the criminal justice process that are available in the community"); American Ass'n ofCorrectional Psychologists, Standards for Psychological Services in Adult Jails and Prisons, 7Crim. Just. & Behav. 81, § 32 discussion, at 109 (1980) ("Transfer . . . for clients who requireintensive treatment should occur when the quality of available services within the correctionalfacility is not equivalent to that found in local community facilities.");

c.    Mental Health decision-makers must be independent of other prison officials.    

    Standards for Adult Correctional Insts. § 3-4327 (American Correctional Ass'n & Comm'non Accreditation for Corrections 3rd ed. 1990) (mandatory) ("Written policy, procedure, andpractice provide that all medical, psychiatric, and dental matters involving medical judgement arethe sole province of the responsible physician and dentist, respectively."); id., § 3-4331 comment("No member of the correctional staff shall approve or disapprove requests for attendance at sickcall."); Foundation/Core Standards for Adult Local Detention Facilities § FC2-5076 (AmericanCorrectional Ass'n & Comm'n on Accreditation for Corrections 1989) (mandatory) ("Medical,dental, and mental health matters involving medical judgements are the sole province of theresponsible physician, dentist, and psychiatrist or qualified psychologist."); Fed. Standards forPrisons and Jails § 5.02 (U.S. Dept. of Justice 1980) ("The designated responsible physician isunder no restrictions imposed by the facility administration regarding medical decisions; however,security regulations applicable to facility personnel also apply to health personnel"); id., § 5.19("No inmate or correctional officer inhibits or delays an inmate's access to medical services orinterferes with medical treatment"); American Ass'n of Correctional Psychologists, Standards forPsychological Services in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 05, at 89 (1980)(essential) ("The psychologists, and the staff activities for which these individuals are responsible,have professional autonomy regarding psychological services, within the constraints of appropriatesecurity regulations applicable to all institutional personnel"); id. (discussion) ("Psychologicalservices personnel need to be granted sufficient autonomy to practice their profession, since inthese matters their training makes them the best qualified to make appropriate psychologicaljudgments."); American Psych. Ass'n, General Guidelines for Providers of Psychological Services§ 3.2, at 8 (1987) ("Psychologists pursue their activities as members of the independent,autonomous profession of psychology."); id. (illustrative statement) ("Psychologists, as memberof an independent profession, are responsible both to the public and to their peers throughestablished review mechanisms. Psychologists are aware of the implications of their activities forthe profession as a whole."). Standards for Health Services in Prisons, National Comm'n onCorrectional Health Care, P-03 (essential)(1997) ("Written policy and defined procedures require,and actual practice evidences, that clinical decisions and actions regarding the health servicesprovided to inmates are the sole responsibility of qualified health care professionals and are notcompromised for security reasons.")

    2.    Preliminary Mental Health Screening of Incoming Prisoners and Referrals forTreatment

a.     Prisons and jails must have a system to screen incoming inmates to identify those withmental illness.

     Standards for Adult Correctional Institutions, § 3-4343 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990);("Written policy, procedure, and practicerequire medical, dental, and mental health screening to be performed by health-trained or qualifiedhealth care personnel on all inmates, excluding intrasystem transfers, upon the inmate's arrivalat the facility."); id., § 3-4343 (intrasystem transfers are to receive a health screening upon arrival); Standards for Health Services in Prison, National Comm'n on Correctional Health Care,P-32, at 41 (1997) ("Written policy and defined procedures require, and actual practice evidences,that receiving screening is performed by qualified health care personnel on all inmates immediatelyupon their arrival at the prison. Persons who are . . . mentally unstable, or otherwise urgentlyin need of medical attention are referred immediately for emergency care."); Standards for HealthServices in Jail, National Comm'n on Correctional Health Care, J-30 (1996) (same);

American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.1.b(1)(a) (jails) (1989)("Immediately upon admission to the jail, inmates should be asked questions pertaining to theirmental health"); id., § D.1.b(1)(a) (prisons) ("Receiving mental health screening will be carriedout immediately upon admission to the prison . . . ."); American Ass'n of CorrectionalPsychologists, Standards for Psychological Services in Adult Jails and Prisons, 7 Crim. Just. &Behav. 81, § 23, at 103 (1980) (essential) ("Receiving screening is performed on all inmates uponadmission to facility before being placed in the general population or housing area. . . . Inmatesidentified as having mental problems are referred for a more comprehensive psychologicalevaluation."); id. (discussion) (screening must be done immediately at the time of booking oradmission. Placing two or more inmates in a holding cell/room pending screening several hourslater or the next morning fails to meet compliance); Fed. Standards for Prisons and Jails § 5.15(U.S. Dept. of Justice 1980) ("Written policy and procedure provide that receiving screening isperformed on all inmates by qualified health personnel or a specially trained correctional officerupon admission to the facility before the inmate is placed in the general population or housingarea."); Standard Minimum Rules for the Treatment of Prisoners: Resolution of the First UnitedNations Congress on the Prevention of Crime and the Treatment of Offenders, E.S.C. Res. 663C,U.N. ESCOR, 24th Sess., Supp. No. 1, ¶ 24, U.N. Doc. A/CONF/611 (1955), amended byE.S.C. Res. 2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977)(medical services) ("The medical officer shall see and examine every prisoner as soon as possibleafter his admission and thereafter as necessary, with a view particularly to the discovery ofphysical or mental illness and the taking of all necessary measures; . . . the noting of physicalor mental defects which might hamper rehabilitation . . . ."); James R.P. Ogloff et al., Screening,Assessment, and Identification of Services for Mentally Ill Offenders, in Mental Illness inAmerica's Prisons 61, 64 (Henry J. Steadman and Joseph J. Cocozza eds. [National Coalition forthe Mentally Ill in the Criminal Justice System], 1993) (writing that the mandated medicalexamination given at admission "must also include a screening for mental illness."); Fred Cohen,The Legal Context for Mental Health Services, in Mental Illness in America's Prisons 25, 56(Henry J. Steadman and Joseph J. Cocozza eds. [National Coalition for the Mentally Ill in theCriminal Justice System], 1993) (stating that to learn how many seriously mentally ill inmates arein their care, prison officials must have "some type of initial screening and assessment, someregular follow-up, and some type of decent record-keeping. The epidemiological question is notsatisfactorily answered by simply consulting medication lists, since in many jurisdictions such listsinclude the dispensing of tranquillizers or sleep aides and, thus, are not parallel to a list of thementally ill.").

    See also Madrid v. Gomez, 889 F. Supp. 1146, 1218 (N.D. Cal. 1995)("It is importantthat a mental health care system effectively identify those inmates in need of mental health services, both upon their arrival at the prison and during their incarceration. . . . [M]entally illprisoners may not seek out help where the nature of their mental illness makes them unable torecognize their illness or ask for assistance."); Langley v. Coughlin, 715 F. Supp. 522, 540(S.D.N.Y. 1989), aff'd, 888 F.2d 252 (2nd Cir. 1989) (finding "failure to take into account theinmate's prior psychiatric history" would be violation of Eighth Amendment); id. at 541 ("failureto inquire about the patient's prior history reflects a pattern of inadequate medical care to thementally ill inmates housed on SHU [Special Housing Unit].");

Arnold on behalf of H.B. v. Lewis, 803 F. Supp. 246 (D. Ariz. 1992); Balla v. Idaho State Bd.of Corrections, 595 F. Supp. 1558, 1577 (D. Idaho 1984) (quoting Ruiz, 503 F. Supp. at 1545)(quoted in Madrid v. Gomez, 889 F. Supp. 1146, 1256-57 (N.D. Cal. 1995)) (stating that theremust be a "systematic program for screening and evaluating inmates in order to identify those whorequire mental health treatment."); Barnes v. Government of Virgin Islands, 415 F. Supp. 1218(D.V.I. 1976); Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109, *5 (E.D. Cal. 1995)(finding Eighth Amendment violation where "defendants do not have an adequate mechanism forscreening inmates for mental illness, either at the time of reception or during incarceration."); id.at *12 ("The magistrate judge found that "[i]n order to provide necessary mental health care toprisoners with serous mental disorders, there must be a system in place to identify thoseindividuals, both at the time they are admitted to the Department of Corrections and during theirincarceration.'"); Ruiz v. Estelle, 503 F. Supp. 1265 (S.D. Tex. 1980), aff'd in part and rev'din part, 679 F.2d 1115 (5th Cir. 1982), cert. denied, 460 U.S. 1042 (1983).

b.    Contents of the Preliminary Mental Health Screening

    Standards for Adult Correctional Institutions. § 3-4344 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990) (mandatory) (preliminary screening)("All findings are recorded on a screening form approved by the health authority. The screeningincludes at a minimum the following: Inquiry into whether the inmate is being treated for amedical, dental, or mental health problem; whether the inmate is presently on medication; whetherthe inmate has a current medical, dental, or mental health complaint; Observation of generalappearance and behavior . . "); National Comm'n on Correctional Health Care, Standards forHealth Services in Prison P-32, at 41 (1997)(essential) (Receiving Screening) ("At minimum, thescreening process includes the following: (1) Inquiry into current and past illnesses, healthproblems, and conditions including . . . mental illness including suicide risk. . . (2) Observationof the following: behavior, which includes state of consciousness, mental status (including suicidalideation), appearance, conduct, tremors, [other indicators of medical problems] and needle marksor other indications of drug abuse. 4) Notation of the disposition of the patient, such as immediatereferral to an appropriate health care service, placement in the general inmate population and thelater referral to an appropriate health care service, or placement in the inmate population. 5)Documentation of the date and time when referral/placement actually takes place."); NationalComm'n on Correctional Health Care, Standards for Health Services in Jail J-30, at 41 (1996)(same); American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.1.a(1) (jails) (1989)("Receiving mental health screening consists of observation and structured inquiry designed to prevent newly arrived inmates, who may be acutely or chronically mentally ill, from beingadmitted to the facility's general population and to refer these inmates rapidly for a more full scalemental health evaluation."); id., § C.1.b(1)(a) (jails) ("Immediately upon admission to the jail,inmates should be asked questions pertaining to their mental health, i.e., suicide potential, priorpsychiatric hospitalizations, and current medications, both being taken and prescribed."); id.,§ D.1.a(1) (prisons) ("Receiving mental health screening consists of observation and structuredinquiry designed to assure that the prisoner newly arriving at the facility or reception center, whomay require mental health evaluation as a result of mental illness or developmental disability, isreferred for mental health evaluation and is placed in the proper living environment."); id.,§ D.1.b(1)(a) (prisons) ("Receiving mental health screening . . . will include the review ofpertinent records accompanying the inmate. It will also include inquiry into past mental healthtreatment and screening questions designed to identify the signs of severe emotional, intellectual,and/or behavioral problems such as hallucinations, suicidal and/or homicidal thinking, severethought disorganization, or bizarre behavior."); American Ass'n of Correctional Psychologists,Standards for Psychological Services in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 23,at 103 (1980) (discussion) ("The method of receiving screening should include: (a) a review ofpapers or records accompanying the inmate; (b) completion of the receiving screening form withthe help of the inmate_i.e., a review of the inmate's history concerning suicidal behavior, sexualdeviancy, mental health history (including alcohol and other substance abuse), mentalhospitalizations, seizures, patterns of violence and aggression; and (c) visual observation of theinmate's behavior (looking for signs of delusions, hallucinations, communication difficulties,peculiar speech and/or posturing, impaired level of consciousness, disorganization, memorydeficits, depression, and evidence of self-mutilation)."); Fed. Standards for Prisons and Jails§ 5.15 (U.S. Dept. of Justice 1980) ("Where receiving screening is performed by a correctionalofficer and full exposure of the body is required, the officer is of the same sex as the inmate. Thefindings are recorded on a printed screening form approved by the health authority. The screeningincludes the following: . . . Behavioral observation, including state of consciousness and mentalstatus, appearance, conduct, tremor and sweating.").

c.     Preliminary screenings must be conducted in a confidential atmosphere.

    Deborah L. Dennis, The National Work Session: Recommendations for Action, in MentalIllness in America's Prisons 213, 215 (Henry J. Steadman and Joseph J. Cocozza eds. [NationalCoalition for the Mentally Ill in the Criminal Justice System], 1993) ("Screening should beconducted in a setting respectful of the privacy and dignity of the inmate, and where sensitive andvalid information may be obtained."). See also American Ass'n of Correctional Psychologists,Standards for Psychological Services in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 06,at 90 (1980) (discussion) ("Physical arrangements should be conducive to human dignity, self- respect, and promoting the optimal functioning of both the inmate clients and the professional staffmembers. [Necessary equipment includes] a desk, a desk chair, . . . at least one comfortable chair(preferably with armrests) for the clients, . . . an office with walls to the ceiling and no windows(or with drapes which can be drawn for privacy).").

d.     Screeners need training in mental illnesses.     American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.1.b(1)(c) (1989) (jails)("Receiving mental health screening is usually done primarily by the booking officer. Specialtraining in mental health screening should be provided to the officers who perform this task.");id., § b(1)(e) (jails) ("Psychiatrists [role includes] (ii) training officers to use the screeninginstrument."); id., b(2)(c) (jails) ("The intake mental health screening should be performed by amember of the health care staff."); id., § D.1.b(1)(c) (prisons) ("Receiving mental healthscreening should be performed by a qualified mental health professional or by a trainedcorrectional officer at the time of admission."); id., b(1)(e) ("Psychiatrists' role in the provisionof receiving mental health screening [includes (ii)] ongoing training of correctional officers andhealth and mental health personnel in the use of receiving mental health screening forms andprocedures."); id., b(2)(c) (prisons) ("The intake mental health screening should be performed bya member of the health care staff."); id., b(2)(e) (stating that psychiatrists' primary roles in intakemental health screening includes "(i) the development of the appropriate intake mental healthscreening forms and informational material [and] (ii) the training of health care staff in the use ofmental health screening forms and the informational (orientation) materials."); id., b(3)(c)("Mental health evaluations or consultations are performed by an appropriately trained mentalhealth professional").

    See also Langley v. Coughlin, 715 F. Supp. 522 (S.D.N.Y. 1989), aff'd, 888 F.2d 252(2nd Cir. 1989); Madrid v. Gomez, 889 F. Supp. 1146 (N.D. Cal. 1995) (stating that screeningmust be performed by people with proper training and background).

3.    Mental Health Assessment of All Inmates

a.     All newly committed inmates should receive a detailed mental health evaluation shortlyafter admission.

    Standards for Adult Correctional Institution § 3-4345 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990) (Full Health Appraisal) ("Written policy,procedure, and practice require that health appraisal for each inmate, excluding intrasystemtransfers, is completed within 14 days after arrival at the facility."); Standards for Health Servicesin Prison, National Comm'n on Correctional Health Care P-35, at 46 (1997)(essential) (mentalhealth evaluation) ("Written policies and defined procedures require, and actual practiceevidences, post-admission evaluation of all inmates by qualified mental health personnel[physicians, psychiatrists, psychologists, nurses, physician assistants, psychiatric social workers,and others who by virtue of their education, credentials, and experience are permitted by law toevaluate and care for the mental health needs of patients] within 14 days of admission.");Standards for Health Services in Jail, National Comm'n on Correctional Health Care P-39, at50 (1996) (same); American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails andPrisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29,§ C.1.b(2)(a) (1989)(jails) ("Intake mental health screening should take place within 24 hours of admission to a jail.");id., § D.1.a(2) (prisons) ("Intake mental health screening may take place somewhat later [thanreceiving mental health screening]."); id., § D.1.b(2)(a) (prisons) ("Intake mental health screening should take place within seven days of admission to a prison or reception center."); Fed.Standards for Prisons and Jails § 5.16 (U.S. Dept. of Justice 1980) ("Health appraisal datacollection is completed for each inmate within fourteen days after admission to the facility . . .If a health appraisal as required herein has been completed within the previous 90 days prior toadmission to the facility and all results have been transferred, the recollection of this data may bewaived at the discretion of the responsible physician."); American Ass'n of CorrectionalPsychologists, Standards for Psychological Services in Adult Jails and Prisons, 7 Crim. Just. &Behav. 81, § 24, at 104 (1980) (essential) ("In a prison setting, all newly committed inmates withsentences over one year shall be given a psychological evaluation within one month ofadmission.").

b.    Contents of Mental Health Assessment

    National Comm'n on Correctional Health Care, Standards for Health Services in PrisonP-34, at 44 (1997)(essential) (health assessment) ("A full health assessment . . . includes theseitems: a review of the receiving results; the collection of additional data to complete the medical,dental, and mental health histories; . . . a physical examination including comments about mentalstatus . . . ."); id., P-35, at 46 (mental health evaluation)(discussion)("The post-admission mentalhealth assessment includes: (1) a structured interview by mental health staff in which inquiries intothe items listed below are made: history of psychiatric hospitalization and outpatient treatment;current psychotropic medications; suicidal ideation and history of suicidal behavior, drug usage,alcohol usage, history of sex offenses; history of expressly violent behavior; history ofvictimization, special education placement, history of cerebral trauma or seizures, and emotionalresponse to incarceration"); National Comm'n on Correctional Health Care, Standards for HealthServices in Jail, J-39, at 50-51 (1996) (same); Standards for Adult Correctional Institutions. § 3-4345 (American Correctional Ass'n & Comm'n on Accreditation for Corrections 3rd ed. 1990)(Full Health Appraisal) ("Health appraisal includes the following: review of the earlier receivingscreening; collection of additional data to complete the medical, dental, mental health, andimmunization histories; . . . other tests and examinations as appropriate; medical examination,including review of mental and dental status; . . . initiation of therapy when appropriate.");American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.1.a(2) (1989) (jails) ("Intakemental health screening is a component of the full scale admission workup and consists of adetailed medical and mental health examination."); id., § D.1.a(2) (prisons) "Intake mental healthscreening . . . consists of a more detailed, thorough, and structured mental health examinationwhich is administered to all recently arriving prisoners as part of the facility's admissionprocess."); Fed. Standards for Prisons and Jails § 5.16 (U.S. Dept. of Justice 1980) ("Healthappraisal data collection . . . includes . . . additional data to complete the medical, immunization,and mental health history."); American Ass'n of Correctional Psychologists, Standards forPsychological Services in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 24, at 104 (1980)(essential) ("Such routine [psychological] evaluations are brief and include (but are not necessarilylimited to) behavioral observation, a records review, group testing to screen for emotional andintellectual abnormalities, and a written report of initial findings. Referral for more intensive,individual assessment is made when appropriate.").

4.    Follow up Referrals from Preliminary Screening and Mental Health Assessment

a.     Inmates should receive a thorough psychiatric evaluation within a short period after staffmake a referral

    Standards for Adult Correctional Insts. § 3-4349 (American Correctional Ass'n & Comm'non Accreditation for Corrections 3rd ed. 1990) ("Written policy, procedure, and practice,approved by the health authority, provide for comprehensive individual evaluation by amultidisciplinary mental health team for specially referred inmates. The evaluation is completedwithin 14 days after the date of referral and includes at least the following: review of mentalhealth screening and appraisal data; direct observations of behavior; collection and review ofadditional data from individual diagnostic interviews and tests assessing personality, intellect, andcoping abilities; compilation of the individual's mental health history; development of an overalltreatment/management plan with appropriate referral."); American Psychiatric Ass'n, Guidelinesfor Psychiatric Services in Jails and Prisons, in Psychiatric Services in Jails and Prisons, TaskForce Report 29, § D.1.b(1)(c) (1989) ("Where receiving mental health screening is doneprimarily by a trained correctional officer, written policies and procedures will define amechanism for prompt referral to and evaluation by a mental health professional whereappropriate."); id., b(2)(e)(iii) (stating that psychiatrists' primary role in intake mental healthscreening includes "the development of written referral procedures for inmates identified duringthe intake mental health screening as [sic] process as requiring mental health evaluation"); id.,b(3)(a) ("Specific written procedures providing for . . . referral shall be part of the facilities [sic]mental health services plan."); id., § C.1.a(3) (1989) (jails) ("Mental health evaluation is acomprehensive mental health examination which is appropriate to the particular, suspected levelof disability and which is focused on the suspected mental illness or developmental disability.");id., § C.1.b(3)(a) (jails) ("Mental health evaluation shall be provided within 24 hours from thetime of referral. In cases of urgency, provision shall be made for immediate evaluation uponreferral. Referral may be made by (i) a screening procedure, (ii) custodial staff, or (iii) self- referral."); id., § D.1.b(3)(a) (prisons) ("Mental health evaluation or an appropriate alternativeresponse shall be provided in no more than 24 hours from the time of referral. In cases ofurgency, provision shall be made for immediate evaluation upon referral."); American Ass'n ofCorrectional Psychologists, Standards for Psychological Services in Adult Jails and Prisons, 7Crim. Just. & Behav. 81, § 27, at 106 (1980) (essential) ("Crisis evaluations should be conductedas soon as possible, but not later than 24 hours after the staff member has been notified.Subsequently, a report of the session(s) is written and appropriately filed."); id. (discussion)("Qualified psychological services personnel conduct these crisis evaluations. Facility staff shouldhave sufficient training to provide adequate supportive care until the evaluation can be made.");id., § 26, at 105-06 (essential) ("The individual assessment of all inmates referred for a specialcomprehensive psychological appraisal is completed within 14 days after the date of the referral.. . . This standard as applied in a prison setting includes: (a) Reviewing earlier screeninginformation and psychological evaluation data. (b) Collecting and reviewing any additional datato complete the individual's mental health history, (c) collecting additional data from observationsby correctional staff, (d) administering tests which assess levels of cognitive and emotional functioning and the adequacy of coping mechanisms, (e) writing a report describing the results ofthe assessment procedures, including an outline of a recommended plan of treatment whichmentions any indication by the inmate of a desire for help, (f) communicating results to referralsource, and (g) writing and filing a report of findings and recommendations.").

5.    Monitoring and Diagnosis of Inmates with Mental Illness

a.     Every correctional facility must have procedures for custody staff and inmates to referinmates needing mental health treatment or evaluation.

    American Ass'n of Correctional Psychologists, Standards for Psychological Services inAdult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 22, at 102 (1980) (essential) ("There is awritten, implemented policy approved by the chief psychologist (and in accordance withheadquarters guidelines in a multifacility system) regarding access to psychological services for(1) postadmission inmates with emergency problems and for (2) daily referrals of nonemergencyproblems covering both scheduled and unscheduled care."); id. (discussion) ("Institution staffshould refer to psychological services personnel those inmates in the general population who aresuspected of emotional disturbance. Correctional officers or jailers, all of whom should be trainedin recognition of symptoms of mental disturbance, provide 24-hour-a-day observation and areavailable to receive complaints of this nature from inmates. The obligation of these staff membersis to pass this information along to psychological services personnel for screening/triaging orassignment of treatment priorities, followed by referrals for treatment as indicated.");Foundation/Core Standards for Adult Local Detention Facilities § C2-5182 (AmericanCorrectional Ass'n & Comm'n on Accreditation for Corrections 1989) (certification standard)("Written policy and procedure require postadmission screening and referral for care of mentallyill or retarded inmates whose adaptation to the correctional environment is significantlyimpaired."); American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons,in Psychiatric Services in Jails and Prisons, Task Force Report 29, § C.1.b(3)(a) (1989) (jails)("Mental health evaluation shall be provided within 24 hours from the time of referral. In casesof urgency, provision shall be made for immediate evaluation upon referral. Referral may be madeby . . . (ii) custodial staff, or (iii) self-referral. Specific written procedures providing for thesetypes of referral shall be part of the facility's mental health services plan."); ABA Criminal JusticeMental Health Standards § 7-2.6(b) (American Bar Association 1984) (postarrest obligations ofpolice and custodial personnel) ("When arresting or custodial officers or other personnel observea detainee whose conduct or demeanor is indicative of mental illness or mental retardation, mentaldisturbance, disorientation or distress, or whose behavior is self-injurious or is indicative of thepossibility of suicide, such officers or personnel have a duty to report those observations promptlyto the official in charge of the detention or holding facility. Such official, after promptlyconfirming the need to do so, should summon a mental health or mental retardation professionalto provide emergency evaluation, treatment, or habilitation."); Fed. Standards for Prisons andJails § 5.29 (U.S. Dept. of Justice 1980) ("Written policy and procedure require that screeningand referral for care are provided to mentally ill or retarded inmates whose adaptation to thecorrectional environment is significantly impaired.").    See also Madrid v. Gomez, 889 F. Supp. 1146, 1219 (N.D. Cal. 1995)(It is insufficientfor a prison to rely upon mental health referrals from custody staff and inmates; staff psychiatristsand psychologists should visit the cellblocks regularly.); Langley v. Coughlin, 715 F. Supp. 522,541 (finding that "an absence of criteria for DOCS [Department of Correctional Services]personnel to follow concerning when to make referrals to OMH [Office of Mental Health""reflects a pattern of inadequate medical care to the mentally ill inmates housed on SHU [SpecialHousing Unit]."); James R.P. Ogloff et al., Screening, Assessment, and Identification of Servicesfor Mentally Ill Offenders, in Mental Illness in America's Prisons 61, 64 (Henry J. Steadman andJoseph J. Cocozza eds. [National Coalition for the Mentally Ill in the Criminal Justice System],1993) ("[M]any inmates, who develop mental health problems after being incarcerated, or whoseproblems become more severe under those circumstances, fall between the cracks left open bylimiting mental health assessments to the time of admission and following crisis episodes. For thisreason, it is important for prisons to implement a comprehensive screening and evaluationprogram, and to involve all personnel working with inmates in prisons in the process ofcontinuously identifying inmates who may display symptoms of mental illness and who mayrequire intervention." "[I]t is important for mental health programs in prisons to include formaland informal mechanisms for personnel to make referrals to the programs. For example,corrections officers should be able to talk with mental health personnel about an inmate who theynotice to have undergone serious changes in mood or behavior. Likewise, there should be a formalprocess for staff and duty officers to refer inmates to the mental health program").

6.    Mental Health Treatment Modalities

a.     Correctional facilities must provide a range of treatment modalities to inmates withmental disabilities.

    Standards for Adult Correctional Institutions. § 3-4380 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990), § 3-4386 ("Treatment offerings shouldinclude group therapy and group and individual counseling."); Fed. Standards for Prisons andJails § 5.30 (U.S. Dept. of Justice 1980) ("Special programs exist for . . . (2) inmates with severeemotional disturbances, and (3) retarded and developmentally disable inmates who require closemedical, psychiatric, psychological, or habilitative supervision. A written individualized plan foreach of these inmates is approved by a physician or qualified mental health professional afterappropriate multidisciplinary consultation and in accord with written policy. The plan includesdirections to medical and nonmedical personnel regarding their roles in the care, supervision andhabilitation of these inmates."); American Psychiatric Ass'n, Guidelines for Psychiatric Servicesin Jails and Prisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29,§ D.3.a(1) (1989) (prisons) ("Given the relatively long-term nature of prison confinement, a widerrange of mental health treatment modalities [than needed in lock-ups and jails] will be called for. These include: (1) a full range of appropriate mental health treatment services as described in theprinciples." (citing American Psychiatric Ass'n, Principles Governing the Delivery of PsychiatricServices in Lock-Ups, Jails and Prisons, in Psychiatric Services in Jails and Prisons, Task ForceReport 29, § F.5 (referring to "a. an acute care program, b. a chronic care program, c. a transitional care program, and d. an outpatient treatment program." As part of providing atherapeutic milieu, prisons must assure "the availability of mental health personnel and regularaccess to such personnel by the inmate population." "Psychotherapies of different types, includingindividual and group, supportive, and insight, should be available as needs require and resourcescan provide. Group therapy programs have been found to be especially suitable in these settingsand to particular patient populations including substance abusers, sex offenders, etc. . . . Behaviormodification programs may be helpful, but they must require informed consent and must haveexternal, independent, professional monitoring. Family therapy programs are to be especiallyencouraged."))); American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails andPrisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29, § C.3.a (jails)("Considering the short-term nature of most jail confinements, treatment will generally emphasizethe prescription of psychotropic medications. For those inmates whose pre-trial confinements orsentences may be of longer term, some verbal therapies may also become part of the treatmentregimen."); Standards for Health Servs. in Correctional Institutions., Mental Health Care Services§ C, at 31-32 (American Pub. Health Ass"n 1976) ("Principle: Direct treatment services shouldbe provided in a context of varied modalities, with emphasis on eclectic breadth. . . . SatisfactoryCompliance: The following direct treatment services shall be made available as a minimum: 1.Crisis intervention . . . 2. Brief and extended evaluation/assessment. 3. Short-term Therapy:Group and individual. 4. Long-term Therapy: Group and Individual. 5. Therapy with family andsignificant others. 6. Counseling must be available for all inmates. . . . 7. Medication. . . . 8. De- toxicification. 9. In-patient hospitalization for the severely disturbed."); American Ass'n ofCorrectional Psychologists, Standards for Psychological Services in Adult Jails and Prisons, 7Crim. Just. & Behav. 81, § 37, at 112 (1980) (essential) ("The facility will provide a multiplicityof appropriate programs."); id. (discussion) ("The requirement that there be a reasonable numberof alternative programs is intended to recognize the complexity and uniqueness of each inmateclient and to prevent exclusive reliance upon any particular treatment modality, such as group ormilieu therapy. This is not intended to mandate that every facility provide every conceivabletreatment program; it does require a reasonable number of alternatives based upon the institution'scharacteristics and the needs of its inmates.").    

b.    Treatment must consist of more than just medication.

    Standards for Adult Correctional Institutions. § 3-4341 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990) (mandatory) ("Written policy, procedure,and practice provide for the proper management of pharmaceuticals and address the followingsubjects: . . . prescription practices, including requirements that (1) psychotropic medications areprescribed only when clinically indicated as one facet of a program of therapy.");Foundation/Core Standards for Adult Local Detention Facilities § FC2-5087 (AmericanCorrectional Ass'n & Comm'n on Accreditation for Corrections 1989) (mandatory) (Prescriptionpractices that require "(a) psychotropic medications are prescribed only when clinically indicatedas one facet of a program of therapy."); National Comm'n on Correctional Health Care P-27.5(h),at 34 (1997) (essential) (Pharmaceuticals) ("The prescribing of psychotropic or behavior- modifying medications only when clinically indicated (as one facet of a program of therapy) andnot for disciplinary reasons."); Standards for Health Services in Jail, National Comm'n on Correctional Health Care, J-30.5(h) (1996) (same).

    See also Marnie E. Rice & Grant T. Harris, Treatment for Prisoners with Mental Disorder,in Mental Illness in America's Prisons 91, 97 (Henry J. Steadman and Joseph J. Cocozza eds.[National Coalition for the Mentally Ill in the Criminal Justice System], 1993) ("[I]n the end,though an essential part of the clinical arm[am]entarium, it must be concluded that drugs will notsuffice as the only clinical tool for prisoners with mental disorder." (citing G.T. Harris, TheRelationship Between Neuroleptic Drug Dose and the Performance of Psychiatric Patients inMaximum Security Token Economy Program, 20 J. Behavior Therapy & Experimental Psychiatry57 (1989), M.E. Rice et al., Violence in Institutions: Understanding, Prevention, and Control(1989), M.E. Rice et al., Planning Treatment Programs in Secure Psychiatric Facilities, in Lawand Mental Health: International Perspectives 162 (D. Weisstub ed., 1990))).

    See also Langley v. Coughlin, 715 F. Supp. 522, 540 (S.D.N.Y. 1989), aff'd, 888 F.2d252 (2nd Cir. 1989) (finding "failure to provide any meaningful treatment other than medication"would violate Eighth Amendment); Madrid v. Gomez, 889 F. Supp. 1146, 1218 (N.D. Cal. 1995)(finding constitutional violations in system where "[t]reatment for seriously ill inmates is primarilylimited to medication management through use of antipsychotic or psychotropic drugs, andintensive outpatient treatment is not available").

c.    Each inmate must have an individualized treatment plan.

    American Ass'n of Correctional Psychologists, Standards for Psychological Services inAdult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 31 at 108 (1980) (essential) ("A writtentreatment plan exists for all inmates requiring psychological services. This is developed by apsychologist in collaboration with other personnel and includes directions for nonpsychologicalservices personnel regarding their roles in the care and supervision of these prisoners."); id.(discussion) ("A treatment plan is a series of written statements which specify the particular courseof therapy and the roles of all personnel in carrying out the plan. It should also include futureplanning for the management of a specific condition. The plan may be brief or as long asnecessary to provide proper care. Jail inmates with short stays may have less detailed plans thanprisoners confined in long-term facilities. The treatment plan should be goal-oriented and shouldspecify, in addition to any nonpsychological activities, at least the following: the extent and natureof the formal psychotherapeutic modality being used, provision for interim progress notes, anda termination summary."); Standards for Health Services in Prison, National Comm'n onCorrectional Health Care P-51 at 65 (1997)(Special Needs Treatment Plans (essential) ("Writtenpolicy and defined procedures guide the care of inmates with special needs requiring close medicalsupervision and/or multidisciplinary care. Included among special needs patients are thefollowing: . . . inmates with serious mental health needs and the developmentally disabled. Foreach of these special needs patients there is a written individualized treatment plan, developed bya physician or other qualified health practitioner."); id (discussion) ("Inmates with serious mentalhealth needs include people with basic psychotic disorders (e.g. manic-depressives); self- mutilators; the aggressive mentally ill; and suicidal inmates. . . A treatment plan is a series ofwritten statements specifying the particular course of therapy and the roles of qualified health careprofessionals in carrying it out. It is individualized, typically multidisciplinary, and based on anassessment of the patients needs, a statement of short and long-term goals as well as the methods by which these goals will be pursued. When clinically indicated, the treatment plan gives inmatesaccess to the range of supportive and rehabilitative services (such as . . . individual or groupcounseling, and self-help groups) that the treating practioner deems appropriate."); Standards forHealth Services in Jails, National Comm'n on Correctional Health Care, J-49 at 63 (1996)(same);Fed. Standards for Prisons and Jails § 5.30 (U.S. Dept. of Justice 1980)(Inmates with mentaldisabilities must have a "written individualized plan . . . approved by a physician or qualifiedmental health professional after appropriate multidisciplinary consultation and in accord withwritten policy. The plan includes directions to medical and nonmedical personnel regarding theirroles in the care, supervision and habilitation of these inmates.").

    See also Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109, *5 (E.D. Cal. 1995)(finding Eighth Amendment violation where magistrate judge found that medical records containedincomplete or nonexistent treatment plans).

d.     Prisons must have written policies to assure timely delivery of needed mental healthservices.

    Fed. Standards for Prisons and Jails § 5.19 (U.S. Dept. of Justice 1980) ("Written policyand procedure require that inmates' medical complaints are processed, reviewed and respondedto daily by health trained personnel according to priority of need. In all cases, inmates receivetreatment for medical problems promptly by the appropriate level of health personnel. No inmateor correctional officer inhibits or delays an inmate's access to medical services or interferes withmedical treatment.").

    See also Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109, *5 (E.D. Cal. 1995)(finding Eighth Amendment violation where "[t]here are significant delays in, and sometimescomplete denial of, access to necessary medical attention.").

e.    Mental health care should be available on a 24-hour basis.

    Standards for Adult Correctional Institutions. § 3-4350 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 3rd ed. 1990) (mandatory) ("Written policy, procedure,and practice provide for 24-hour emergency medical, dental, and mental health care availabilityas outlined in a written plan. The plan includes arrangements for . . . use of one or moredesignated hospital emergency rooms or other appropriate health facilities; emergency on-callphysician, dentist, and mental health professional services when the emergency health facility isnot located in a nearby community; security procedures providing for the immediate transfer ofinmates when appropriate."); American Psychiatric Ass'n, Guidelines for Psychiatric Services inJails and Prisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29, § C.2.b(1989) (jails) (crisis intervention) ("Essential [crisis intervention] mental health services [include](2) twenty-four hour availability of mental health professionals to conduct evaluations, . . . (5)twenty-four hour availability of a psychiatrist to clinically evaluate patients, after initialevaluation, and to prescribe emergency medication."); id., § D.2.b (prisons) (crisis intervention)("Essential [crisis intervention] mental health services [include] (2) availability of a psychiatristto consult with on a 24-hour basis with reference to inmate management, (3) twenty-four hour availability of a qualified physician to prescribe emergency medications when indicated.");American Pub. Health Ass'n 36 (1986)("It shall be the responsibility of the Mental Health Unitto insure that a program is developed which will be capable of responding 24 hours a day, sevendays a week, to inmates in acute emotional or mental distress. This program shall include . . . thecapability for immediate hospitalization of severely psychotic individuals or suicide risks . . .").

f.    Inmates must be provided with information about mental health services in a languagethey can understand.

    Fed. Standards for Prisons and Jails § 5.18 (U.S. Dept. of Justice 1980) ("At the time ofadmission to the facility, inmates are informed orally and in writing of the procedures for gainingaccess to health care services and the processing of complaints regarding health care services. Thisinformation is made available to non-English speaking inmates in a language they can understand.Where the number of non-English speaking inmates is significant and there is another languageknown to a substantial number of them, the information is provided in writing in that language.");Standard Minimum Rules for the Treatment of Prisoners: Resolution of the First United NationsCongress on the Prevention of Crime and the Treatment of Offenders, E.S.C. Res. 663C, U.N.ESCOR, 24th Sess., Supp. No. 1, ¶ 51, U.N. Doc. A/CONF/611 (1955), amended by E.S.C.Res. 2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977) (institutionalpersonnel) ("(1) The director, his deputy, and the majority of the other personnel of the institutionshall be able to speak the language of the greatest number of prisoners, or a language understoodby the greatest number of them. (2) Whenever necessary, the services of an interpreter shall beused."); American Psych. Ass'n, General Guidelines for Providers of Psychological Services§ 1.3, at 3 (1987) (illustrative statement) ("To facilitate the effectiveness of services by increasingthe level of staff sensitivity and professional skills, the psychologist who is designated as directorparticipates in the selection of professional and support personnel whose quaifications includesensitivity and consideration for the language, cultural and experiental background, affectionalorientation, ethnic identification, age, and gender of the users . . ."). See also, Franklin v. Districtof Columbia, -- F.Supp. --, 1997 WL 194453 (D.D.C. 1997).

7.    Medication

a.     Psychotropic medication must be prescribed only by a psychiatrist and in accordance withcontemporary medical standards

    Standards for Health Servs. in Correctional Institutions., Mental Health Care Services§ B.1, at 28 (American Pub. Health Ass'n 1976) ("Psychotropic medication must be prescribedonly by a psychiatrist in accordance with generally accepted pharmacological principals andcontemporary national standards."); id, § C, at 31, 32 ("The following direct treatment servicesshall be made available as a minimum: . . . 7. Medication. In all instances psychotropicmedication shall be prescribed in accordance with generally accepted pharmacological principlesand standards of good practice in the general community, including biochemical monitoring where indicated and evaluation of efficacy in all cases."). Standards for Health Services in Prison,National Comm'n on Correctional Health Care P-27 at 34 (1997)(essential) (Policy should requirethe "prescribing of psychotropic or behavior-modifying medications only when clinically indicated(as one facet of a program of therapy) and not for disciplinary reasons."); Fed. Standards forPrisons and Jails § 5.35 (U.S. Dept. of Justice 1980) ("Written policy and procedure require thatpsychotropic medications are prescribed only by a psychiatrist who has examined the inmate andonly when clinically indicated."); Standards for Adult Correctional Institutions. § 3-4342(American Correctional Ass'n & Comm'n on Accreditation for Corrections 3rd ed. 1990)("Psychotropic drugs, such as antipsychotics, antidepressants, and drugs requiring parenteraladministration, are prescribed only by a physician or authorized health provider by agreement withthe physician, and only following a physical examination of the inmate by the health provider.")

b.    Psychiatrists or physicians should monitor all inmates on psychotropic medications.

    Fed. Standards for Prisons and Jails § 5.35 (U.S. Dept. of Justice 1980) ("Written policyand procedure require that psychotropic medications are prescribed only by a psychiatrist who hasexamined the inmate and . . . that there is an appropriate procedure for monitoring reactions.");American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.3.b(5) (1989) (jails) (statingthat essential mental health services include requiring that "the prescription and monitoring ofpsychotropic medications should be done by a psychiatrist, rather than a general practitioner.");id., § D.3.a(6) (prisons) ("Prescribing and monitoring of psychotropic medications is carried outby a qualified psychiatrist except in emergency situations when a non-psychiatrist physician mayprescribe these medications."); American Pub. Health Ass'n 40 (1986) ("Every inmate receivingpsychotropic medication shall be seen and evaluated by a psychiatrist at least once a week untilstabilized and thereafter at least every two weeks.");

Madrid v. Gomez, 889 F. Supp. 1146, 1258 (N.D. Cal. 1995) ("Psychotropic or behavior-alteringmedication should only be administered with appropriate supervision and periodic evaluation.");Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109, *17 (E.D. Cal. 1995) (findingconstitutional violations in part because "inmates on psychotropic medication are not adequatelymonitored"); Ruiz, 503 F. Supp. at 1339.

c.    A psychiatrist must re-evaluate prescriptions before renewal.

    Fed. Standards for Prisons and Jails, § 5.34 (U.S. Dept. of Justice 1980) ("The facility'sstandard operating procedures for the proper management of pharmaceuticals include . . . [r]e- evaluation by the prescribing provider prior to renewal of a prescription."); Standards for AdultCorrectional Insts. § 3-4341 (American Correctional Ass'n & Comm'n on Accreditation forCorrections 3rd ed. 1990) (mandatory) ("Written policy, procedure, and practice provide for theproper management of pharmaceuticals and address the following subjects: . . . prescriptionpractices, including requirements that . . . (3) the prescribing provider reevaluates a prescriptionprior to its renewal."); Foundation/Core Standards for Adult Local Detention Facilities § FC2-5087 (American Correctional Ass'n & Comm'n on Accreditation for Corrections 1989)(mandatory) ("Written policy, procedure, and practice provide for the proper management of pharmaceuticals and address the following subjects: . . . (2) Prescription practices that require . . .(c) the prescribing provider reevaluates a prescription prior to its renewal."); Foundation/CoreStandards for Adult Local Detention Facilities § FC2-5087 (American Correctional Ass'n &Comm'n on Accreditation for Corrections 1989) (mandatory) ("Written policy, procedure, andpractice provide for the proper management of pharmaceuticals and address the following subjects:. . . 2(b) 'Stop order' time periods are required for all medications.");Standards for HealthServices in Prison, National Comm'n on Correctional Health Care P-27.5(e), at 34 (1997)(Pharmaceuticals)(essential) ("Automatic drug stop orders or required review of all orders forDEA-controlled substances, psychotropic drugs, or any other drug that should be restrictedbecause it lends itself to abuse of [sic] for any other reason dictating that patient compliance bemonitored."); Standards for Health Services in Jails, National Comm'n on Correctional HealthCare J-26.5(e), at 33 (1996) (same).

d.    The formulary should contain a range of psychotropic medications.

    American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails and Prisons, inPsychiatric Services in Jails and Prisons, Task Force Report 29, § C.3.b(4) (1989) (jails) (statingthat essential mental health services include "a full range of psychotropic medications."); id.,§ D.3.a(6) (prisons) (stating that prison mental health systems must assure "availability of a fullrange of psychotropic medications"); Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109,*17 (E.D. Cal. 1995) (finding constitutional violations in part because "it appears that some veryuseful medications are not available because there is not enough staff to do necessary post- medication monitoring. . . . [T]he evidence in the record demonstrates that some medications thatare very effective in the treatment of serious mental disorders are not available.").

e.    Prisoners must receive prescribed medications without interruption.

    Fed. Standards for Prisons and Jails § 5.46 (U.S. Dept. of Justice 1980) ("Inmates receiveall medication in the form and at the times prescribed when they are in the facility, includingadministrative segregation and disciplinary detention, or when they are temporarily off the facilitygrounds."); id., § 5.34 ("The facility's standard operating procedures for the proper managementof pharmaceuticals include . . . [p]rocedures for medication dispensing and administration ordistribution."); American Psychiatric Ass'n, Guidelines for Psychiatric Services in Jails andPrisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29, § D.3.a(6) (1989)("Psychiatrists, along with the facility's pharmacy, should develop and monitor procedures toassure that psychotropic medications are appropriately distributed."); Standards for HealthServices in Prison, National Comm'n on Correctional Health Care P-21, at 27 (1997)(essential)(Medication Administration Training) ("Written policy and defined procedures require, and actualpractice evidences, that personnel who administer medication are trained to do so. They mustreceive training approved by the prison administrator, or his/her designee, regarding matters ofsecurity. In addition, they must receive from the responsible physician training regardingaccountability for administering medications in a timely manner according to physicians' orders, and recording the administration of medications in a manner and on a form approved by the healthauthority."); Fed. Standards for Prisons and Jails § 5.36 (U.S. Dept. of Justice 1980) ("Theperson administering medication has training approved by the health authority; is accountable foradministering medications according to orders; and records the administration of medications ina manner and on a form approved by the health authority. In no event does an inmate dispense oradminister medication.").

f.    A system must be in place for the involuntary administration of psychiatric medicationsin appropriate circumstances.

     Standards for Health Services in Prison, National Comm'n on Correctional Health CareP-67, at 84 (1997) (essential) (forced psychotropic medication) ("Written policy and definedprocedures guide the use of forced psychotropic medication in an emergency situation. This policyand these procedures, while governed by the laws applicable in the jurisdiction, includerequirements for authorization by a physician and specification of the duration of the regimen;when, where, and how the procedures may be used; and treatment plan goals for less restrictivetreatment alternatives as soon as possible. Actual practice is consistent with the policy andprocedures."); Standards for Health Services in Jails, National Comm'n on Correctional HealthCare P-65, at 84 (1996) (same); American Ass'n of Correctional Psychologists, Standards forPsychological Services in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 15, at 97 (1980)(essential) ("Written policies and procedures exist and are implemented which outline theprovision of involuntary treatment in accordance with state and federal laws and regulationsapplicable to the jurisdiction. These are approved by the chief psychologist and are in conformitywith professional ethics and principles promulgated by the American Psychological Association. . . The decision to apply such techniques shall be documented and based on (or, if time pressureprecludes this, followed by) interdisciplinary review."); id. (discussion) ("In those instances whenan involuntary treatment technique is applied, it should be one which has evidence of beingeffective, without side effects, of the least restrictive nature appropriate to the problems beingdealt with, and productive of changes that, had the client been more rational, the individual wouldhave sought."); Standards for Health Servs. in Correctional Institutions., Mental Health CareServices § B.1, at 28 (American Pub. Health Ass'n 1976) ("When by virtue of mental disorder,the public safety is threatened, the public, including the individual who is mentally disordered,shall be protected [by imposing involuntary treatment]. . . . Satisfactory Compliance: 1. Eachcorrectional facility shall provide for the hospitalization and treatment of persons who require itbecause of mental illness."); ABA Criminal Justice Mental Health Standards § 7-2.7(b) (AmericanBar Association 1984) (voluntary and involuntary transfer) ("A detainee who is unable to makethe kind of informed decision set forth in paragraph (a), or who objects to treatment orhabilitation, or who objects to transfer to a mental health, mental retardation, or other appropriatefacility should not be transferred or required to accept treatment or habilitation services except:. . . (ii) when reasonably believed by the responsible professional to be necessary in an emergencyto prevent death or serious physical injury to the detainee or others. An involuntary transferhearing should be initiated not later than [forty-eight] hours after an emergency transfer iseffected.") (brackets in original) (emphasis added).    See also Madrid v. Gomez, 889 F. Supp. 1146, 1221 (N.D. Cal. 1995) (ruling that aprison must have protocols or procedures in place to administer needed involuntary psychiatricmedication promptly, subject to the protections set forth by the Supreme Court in Washington v.Harper, to prevent inmates from "suffer[ing] for an extended period of time before they receivetreatment that should be provided immediately."); Coleman v. Wilson, 912 F. Supp. 1282, 1995WL 559109, *19 (E.D. Cal. 1995) (finding constitutional violations in part because of magistratejudge's finding "(1) that some institutions do not have protocols for the use of involuntarymedication and (2) that involuntary medication is underutilized, which causes harm to inmatesdecompensating as a result of mental illness, which in turn, results in the de facto denial of theprocedural safeguards to which mentally [ill] inmates are entitled.").

g.     Prisoners with serious mental disorders must be transfered to a hospital or to aspecialized unit within the prison system.

    Standards for Health Services in Prisons, National Comm'n on Correctional Health CareP-35, at 46 (1997) (essential) (Mental Health Assessment) ("Inmates thought to be suffering fromserious mental illness or developmental disability are immediately referred for evaluation by aqualified mental health professional. Those who require acute mental health services beyond thatavailable at the prison or whose adaptation to the correctional environment is significantlyimpaired are transferred to an appropriate facility as soon as the need for such treatment isdetermined by qualified mental health personnel."); Standards for Health Services in Jails,National Comm'n on Correctional Health Care J-39, at 50 (1996)(same); Standards for AdultCorrectional Institutions. § 3-4367 (American Correctional Ass'n & Comm'n on Accreditationfor Corrections 3rd ed. 1990) ("Inmates who are severely disturbed and/or mentally retarded arereferred for placement in appropriate noncorrectional facilities or in units specially designated forhandling this type of individual."); id., comment ("Inmates who are severely disturbed and/ormentally retarded are vulnerable to abuse by other inmates and require a inordinate amount ofpersonal attention. An individual is considered severely disturbed when he or she is a danger toself or others or is incapable of attending to basic physiological needs."); Standard Minimum Rulesfor the Treatment of Prisoners: Resolution of the First United Nations Congress on the Preventionof Crime and the Treatment of Offenders, E.S.C. Res. 663C, U.N. ESCOR, 24th Sess., Supp.No. 1, ¶ 82, U.N. Doc. A/CONF/611 (1955), amended by E.S.C. Res. 2076, U.N. ESCOR, 62dSess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977) ("(1) Persons who are found to be insaneshall not be detained in prisons and arrangements shall be made to remove them to mentalinstitutions as soon as possible. (2) Prisoners who suffer from other mental diseases orabnormalities shall be observed and treated in specialized institutions under medical management.(3) During this stay in prison, such prisoners shall be placed under the special supervision of amedical officer."); American Ass'n of Correctional Psychologists, Standards for PsychologicalServices in Adult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 32, at 109 (discussion)("Transfer to a more appropriate institution for clients who require intensive treatment shouldoccur when the quality of available services within the correctional facility is not equivalent to thatfound in local community facilities. Jails and prisons, generally, are inappropriate places to housementally ill and mentally retarded individuals."); id, 81, § 30, at 107 (1980) (essential) ("Inmates awaiting emergency evaluation and/or treatment are housed in a specially designated area withclose-staff or trained-volunteer supervision and sufficient security to protect these individuals.");id. at 108 (discussion) ("In collaboration with the correctional facility's administration, it is theresponsibility of the psychological services staff to make the necessary provisions which willensure the safety and security of inmates suspected of being mentally disturbed. Such individualsare particularly vulnerable to abuse in jail and prison settings."); id., § 33, at 109 (important)("Prison systems will have their own resources for handling severely disturbed inmates, either ina separate facility or specially designated units."); id., discussion ("Psychotic inmates should betransferred to mental health institutions. However, many state mental hospitals are becoming moreopen facilities and resist the admission of disturbed inmates for whom secure housing is required.This standard . . . recognizes a growing trend for correctional systems to develop their ownpsychiatric facilities. "Severe disturbance" means that, in response to mental processes, theindividual is a danger to hm/herself, to others, or is incapable of attending to basic physiologicalneeds."); ABA Criminal Justice Mental Health Standards § 7-9.7(a) (American Bar Association1984) (treatment for mentally ill and mentally retarded offenders sentenced to imprisonment)("Mental health and mental retardation services should be available within the adult correctionalfacility for offenders whose mental illness or retardation is not severe enough to necessitatecommitment to a mental health or mental retardation facility."); American Pub. Health Ass'n 37(1986) ("Appropriately staffed and designated special housing areas should be provided forinmates in need of mental health observation or awaiting mental health evaluation, or in alcoholor drug withdrawal. Mental health observation areas shall allow for maximum observation of allpatients and constant observation of persons who are potentially suicidal. All inmates placed inmental observation areas shall be evaluated by a mental health professional within 12 hours and,in the event that they remain there, shall have a treatment plan developed for them. All patientshoused in mental observation shall be interviewed initially by a psychiatrist and evaluated at leastevery other day by a mental health professional.").

h.    Inmates may not be transferred to a mental hospital without due process

    American Ass'n of Correctional Psychologists, Standards for Psychological Services inAdult Jails and Prisons, 7 Crim. Just. & Behav. 81, § 34, at 109-10 (1980) (essential) ("Transferswhich result in inmates being placed in either facilities (or special units within institutions) whichare specifically designated for the care and treatment of the severely mentally disturbed shallfollow due process procedures, as specified in state/federal statutes, prior to the move beingeffected."); Standards for Health Services in Prisons, National Comm'n on Correctional HealthCare P-35, at 44 (1992) (Mental Health Evaluation) (discussion) ("Acutely suicidal and psychoticinmates are emergencies and should be placed immediately in a treatment setting within the prisonif one is available, or transferred to an appropriate facility if not."); Fred Cohen, The LegalContext for Mental Health Services, in Mental Illness in America's Prisons 25, 49-50 (Henry J.Steadman and Joseph J. Cocozza eds. [National Coalition for the Mentally Ill in the CriminalJustice System], 1993) (summarizing the minimum safeguards established by the Supreme Courtin Vitek v. Jones, 445 U.S. 480, 493-94 (1980)). See also Madrid v. Gomez, 889 F. Supp. 1146,1220 (N.D. Cal. 1995) (Prisoners who have been sent to other institutions for psychiatric care should not be returned in the condition which required care, and should not be allowed quicklyto relapse into the same condition once returned); Arnold on behalf of H.B. v. Lewis, 803 F.Supp.246 (D.Ariz. 1992) (characterizing as "barbaric" treatment of female prisoner who was shuffledback and forth between prison and mental facility).

8.    Informed Consent

a.     Patients must be given the information necessary to make an informed decision aboutwhether to accept a particular treatment.

    Standards for Health Services in Prison, National Comm'n on Correctional Health CareP-70, at 86 (1997)(important) ("written policy and defined procedures require, and actual practiceevidences, that all examinations, treatment, and procedures governed by informed consentpractices applicable in the state are observed for inmate care. The informed consent of next ofkin, guardian, or legal custodian applies when required by law."); Fed. Standards for Prisons andJails § 5.51 (U.S. Dept. of Justice 1980) ("Therapeutic medical treatment specifically designedto benefit an individual inmate is permitted provided that . . . (2) the inmate gives full voluntaryand informed written consent after being informed of the treatment's likely effects, the likelihoodand degree of improvement and/or remission, the hazards of the treatment, the reasonablealternatives to the treatment, and the inmate's ability to withdraw from the treatment withoutpenalty at any time."); id., § 5.44 ("Informed consent of inmates is required for all examinations,treatments, and medical procedures for which informed consent is required in the jurisdiction.");American Ass'n of Correctional Psychologists, Standards for Psychological Services in Adult Jailsand Prisons, 7 Crim. Just. & Behav. 81, § 14, at 96 (1980) (essential) ("All psychologicalexaminations, treatments, and procedures affected by the principle of informed consent in thejurisdiction are likewise observed for inmate care. . . . An appropriate form will be used todocument compliance."); id. (discussion) ("Informed consent is the permission granted by theclient to a staff member for the performance of a specified treatment, examination, or procedureafter receiving the material facts regarding the nature, consequences, risks, alternatives, and thelevel of confidentiality surrounding the proposed technique."); Foundation/Core Standards forAdult Local Detention Facilities § FC2-5085 (American Correctional Ass'n & Comm'n onAccreditation for Corrections 1989) ("All examinations, treatments, and procedures affected byinformed consent standards in the community are likewise observed for inmate care."); Standardsfor Adult Correctional Insts. § 3-4372 (American Correctional Ass'n & Comm'n on Accreditationfor Corrections 3rd ed. 1990) ("Written policy, procedure, and practice provide that all informedconsent standards in the jurisdiction are observed and documented for inmate care."); id.,comment ("The facility's policy regarding informed consent . . . should take into accountinformed versus implied consent."); American Pub. Health Ass'n 40 (1986) (quoted in Standards:Legal Issues and the Mentally Disordered Inmate 19 (n.d.)) ("Female inmates shall be informedof the potential risks of taking psychotropic medication while pregnant . . . .").

9.    Seclusion and Restraint

a.     Correctional Facilities Must Have Policies and Procedures Governing the Use ofSeclusion and Restraint

    Standards for Adult Correctional Insts. § 3-4362 (American Correctional Ass'n & Comm'non Accreditation for Corrections 3rd ed. 1990) ("Written policy and procedure govern the use ofrestraints for medical and psychiatric purposes."); id., comment ("Where restraints are part of ahealth care treatment regimen, the restraints used should be those that would be appropriate forthe general public within the jurisdiction. Written policy should identify the authorization neededand when, where, and how restraints may be used and for how long."); American CorrectionalAss'n § 2-4185-1 at 43 (1984 Supp. [sic; other cites in Standards: Legal Issues to an ACAsupplement are to 1994]) (quoted in Standards: Legal Issues and the Mentally Disordered Inmate6 (n.d.)) ("Written policy, procedure, and practice provide that when an offender is placed in afour-point restraint . . . advance approval must be obtained from the warden/superintendent ordesignee. Approval must also be obtained from the designated health authority or designee.");American Correctional Ass'n § 2-4185-1 at 42 (1994 Supp.) ("Four-point restraints should be usedonly in extreme circumstances and only when other types of restraint have proven to beineffective."); id., § 2-4312 at 53 ("Written policy and procedure govern the use of restraints formedical and psychiatric purposes. At a minimum, the policy will address the following: conditionsunder which restraints may be used types of restraints to be applied for specific conditions,identification of person or persons who may authorize the use of restraints, monitoring proceduresfor inmates in restraints. When restraints are part of a health care treatment regimen, the restraintsused should be those that would be appropriate for the general public within the jurisdiction.Written policy should identify the authorization needed and when, where, and how restraints maybe used and for how long."); American Psychiatric Ass'n, Principles Governing the Delivery ofPsychiatric Services in Lock-Ups, Jails and Prisons, in Psychiatric Services in Jails and Prisons,Task Force Report 29, § F.5.d ("(1) Written guidelines for the use of seclusions and restraints arenecessary. These should include criteria and indications as well as staff responsibilities, limitationson time, periodic evaluations, etc., as they apply to that specific facility. Particular attention mustbe devoted to distinctions between the use of these modalities for custodial-administrative purposesand for mental health therapeutic purposes. (2) Orientation of patients should include a carefuldelineation of the policies on seclusions and restraints. (3) Custodial staff as well as mental healthstaff should receive special and continuing education in regard to these policies and procedures.");Standards for Health Services in Prisons, National Comm'n on Correctional Health Care P-66,at 83 (1997) (essential) (Medical Restraints and Therapeutic Seclusion) ("Written policy anddefined procedures require, and actual practice evidences, the appropriate use of medical restraintsand therapeutic seclusion for patients under treatment for a mental illness. They specify the type(s)of restraint that may be used and when, where, how, and for how long restraints or seclusion maybe used. Use is authorized in each case by a physician upon reaching the conclusion that no otherless restrictive treatment is appropriate. For restrained or secluded patients, the treatment planaddresses the goal of removing the inmate from restraint or seclusion as soon as possible."); id.(discussion) ("This standard applies to those situations where the restraints are part of health care treatment. Generally an order for therapeutic restraint should not exceed 12 hours. There shouldbe 15 minute checks by trained personnel or qualified health professionals. The same kinds ofrestraints that would be appropriate for individuals treated in the community may likewise be usedfor medically restraining incarcerated individuals: for example, fleece-lined leather, rubber, orcanvas hand and leg restraints, and strait-jacket. Mental [sic] or hard plastic devices (such ashandcuffs and leg shackles) should not be used for therapeutic restraint. Persons should not berestrained in an unnatural position (for instance, hog-tied, face-down, spread eagled)."); Standardsfor Health Services in Jails, National Comm'n on Correctional Health Care P-466, at 83(1996)(same); American Pub. Health Ass'n 41 (1986)("The use of restraints shall be institutedonly when all attempts to calm the inmate have failed and when, in the judgment of a psychiatristor physician, the threat of serious injury to self and others is so severe as to warrant such aresponse. Restraints shall be used only on the order of a psychiatrist, physician or licensed healthprofessional."); Fred Cohen, The Legal Context for Mental Health Services, in Mental Illness inAmerica's Prisons 25, 57 (Henry J. Steadman and Joseph J. Cocozza eds. [National Coalition forthe Mentally Ill in the Criminal Justice System], 1993) ("Policy and procedure on these practicesshould encompass the following matters: 1. Isolation and restraint are temporary measures tocombat an individual's danger to self or others. 2. A properly trained clinician should authorizethe measures using a least intrusive means approach, as well as previously articulated clinicalcriteria. 3. The time and frequency of use of these measures must be clearly articulated and of arelatively short duration. 4. There must be clear policy on monitoring, re-evaluation anddocumentation. 5. There must be staff training in all of these aspects of the process."); StandardMinimum Rules for the Treatment of Prisoners: Resolution of the First United Nations Congresson the Prevention of Crime and the Treatment of Offenders, E.S.C. Res. 663C, U.N. ESCOR,24th Sess., Supp. No. 1, ¶ 33, U.N. Doc. A/CONF/611 (1955), amended by E.S.C. Res. 2076,U.N. ESCOR, 62d Sess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977) (instruments of restraint)("[C]hains or irons shall not be used as restraints. Other instruments of restraint shall not be usedexcept in the following circumstances: (a) As a precaution against escape during a transfer,provided that they shall be removed when the prisoner appears before a judicial or administrativeauthority; (b) On medical grounds by direction of the medical officer; (c) By order of the director,if other methods of control fail, in order to prevent a prisoner from injuring himself or others orfrom damaging property; in such instances the director shall at once consult the medical officerand report to the higher administrative authority."); id., ¶ 34 ("The patterns and manner of useof instruments of restraint shall be decided by the central prison administration. Such instrumentsmust not be applied for any longer time than is strictly necessary.").

b.    Seclusion and Restraint may not be used as punishment.

    Standard Minimum Rules for the Treatment of Prisoners: Resolution of the First UnitedNations Congress on the Prevention of Crime and the Treatment of Offenders, E.S.C. Res. 663C,U.N. ESCOR, 24th Sess., Supp. No. 1, ¶ 33, U.N. Doc. A/CONF/611 (1955), amended byE.S.C. Res. 2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at 35, U.N. Doc. E/5988 (1977)(instruments of restraint) ("Instruments of restraint, such as handcuffs, chains, irons andstrait-jacket, shall never be applied as a punishment."); American Correctional Ass'n § 3-4183 at 60 (1994 Supp.)("Instruments of restraint, such as handcuffs, irons, and straight [sic] jackets,are never applied as punishment."); American Pub. Health Ass'n 41 (1986) ("Restraints may notbe ordered for punitive purposes."); Standards for Health Services in Prison, National Comm'non Correctional Health Care, P-66 (1997) (essential) ("Written policy and defined proceduresrequire, and actual practice evidences, the appropriate use of therapeutic restraints and therapeuticseclusion for patients under treatment for mental illness. They specify the types of restraint thatmay be used and when, where, how, and for how long restraints or seclusion may be used. Useis authorized by a physician, or other qualified health care professional where permitted by law,upon reaching the conclusion that no less restrictive treatment is appropriate. For restrained orsecluded patients, the treatment plan addresses the goal of removing the inmate from restraint orseclusion as soon as possible. The health care staff does not participate in the non-medical restraintof inmates except for monitoring their health status."); American Psychiatric Ass'n, PrinciplesGoverning the Delivery of Psychiatric Services in Lock-Ups, Jails and Prisons, in PsychiatricServices in Jails and Prisons, Task Force Report 29, § F.5.d(1) (1989) ("Particular attention mustbe devoted to distinctions between the use of [restraint and seclusion] for custodial-administrativepurposes and for mental health therapeutic purposes.").

10.    Suicide Prevention

a.     Correctional facilities must have a basic program for identifying, treating, andsupervising inmates with suicidal tendencies.

    Standards for Adult Correctional Insts. § 3-4364 (American Correctional Ass'n & Comm'non Accreditation for Corrections 3rd ed. 1990) ("There is a written suicide prevention andintervention program that is reviewed and approved by a qualified medical or mental healthprofessional. All staff with responsibility for inmate supervision are trained in the implementationof the program."); id., ("The program should include specific procedures for intake screening,identification, and supervision of suicide-prone inmates."); Foundation/Core Standards for AdultLocal Detention Facilities § C2-5180 (American Correctional Ass'n & Comm'n on Accreditationfor Corrections 1989) (certifiable standard) ("There is a written suicide and intervention programthat is reviewed and approved by a qualified medical or mental health professional. All staff withresponsibility for inmate supervision are trained in the implementation of the program.");Standards for Health Services in Prison, National Comm'n on Correctional Health Care P-53, at68 (1997) (essential) (Suicide Prevention) ("Written policy and defined procedures require, andactual experience evidences, that the prison has a program for identifying and responding tosuicidal individuals. The program components include: identification, training, assessment,monitoring, housing, referral, communication, intervention, notification, reporting, review andcritical incident debriefing"); id. (discussion) ("Key components of a suicide prevention programinclude the following: (1) Training. All staff members who work with inmates should be trainedto recognize verbal and behavioral cues that indicate potential suicide. (2) Identification. Thereceiving screening form should contain observation and interview items related to the inmate'spotential suicide risk. (3) Monitoring. The plan should specify the facility's procedures formonitoring an inmate who has been identified as potentially suicidal. Regular, documentedsupervision should be maintained. (4) Referral. The plan should specify the procedures forreferring potentially suicidal inmates and attempted suicides to mental health care providers orfacilities. (5) Evaluation. This should be conducted by a qualified mental health professional, whodesignates the inmate's level of suicide risk. (6) Housing. A suicidal inmate should not be housedor left alone unless constant supervision can be maintained. If a sufficiently large staff is notavailable that constant supervision can be provided when needed, the inmate should not beisolated. Rather, s/he should be housed with another resident or in a dormitory and checked every10-15 minutes by correctional staff. The room should be as nearly suicide-proof as possible (thatis, without protrusions of any kind that would enable the inmate to hang him/herself). (7)Communication. Procedures for communication between health care and correctional personnelregarding the status of the inmate should exist, to provide clear and current information. (8)Intervention. The plan should address how to handle a suicide in progress, including appropriatefirst-aid measures. (9) Notification. Procedures for notifying prison administrators, outsideauthorities, and family members of potential, attempted, or completed suicides should be in place.(10) Reporting. Procedures for documenting the identification and monitoring of potential orattempted suicides should be detailed, as should procedures for reporting a completed suicide. (11)Review. The plan should specify procedures for medical and administrative review if a suicidedoes occur."). Standards for Health Services in Prison, National Comm'n on Correctional Health Care P-51, at 65 (1996)(same).

    See also Fred Cohen, The Legal Context for Mental Health Services, in Mental Illness inAmerica's Prisons 25, 58 (Henry J. Steadman and Joseph J. Cocozza eds. [National Coalition forthe Mentally Ill in the Criminal Justice System], 1993) ("Suicide screening instruments are easilyavailable through the National Center on Institutions and Alternatives and just as easily used.");James R.P. Ogloff et al., Screening, Assessment, and Identification of Services for Mentally IllOffenders, in Mental Illness in America's Prisons, supra, 61, 63 ("Suicide is one of the mostsevere threats to inmates' safety in prisons. Therefore, any mental health evaluation program mustattempt to identify those inmates who are at a risk for suicide. Unfortunately, due to the low base- rate of suicides in prisons, it is difficult to identify inmates who will likely attempt to take theirown lives.").

    See also Madrid v. Gomez, 889 F. Supp. 1146, 1222 (N.D. Cal. 1995) (finding inadequatea suicide prevention training program consisting of "a three-hour course entitled "Unusual InmateBehavior," which includes a short section on how to identify inmates susceptible to suicide andwhat to do after identifying such an inmate or discovering an attempted suicide . . . a "SuicidePrevention Handbook" [where all staff] were required to read the handbook and complete anaccompanying quiz[,] and some [sporadic] additional in-service training."); Coleman v. Wilson,912 F. Supp. 1282 1995 WL 559109, *5 (E.D. Cal. 1995).

11.    Mental Health Staff

a.     The correctional facility must have sufficient numbers of qualified health personnel ofvarying types to provide adequate evaluation and treatment consistent with contemporarystandards of care.

    Standards for Adult Correctional Institutions. § 3-4336, comment (American CorrectionalAss'n & Comm'n on Accreditation for Corrections 3rd ed. 1990) ("An adequate number ofqualified staff members should be available to deal directly with inmates who have severe mentalhealth problems as well as to advise other correctional staff in their contacts with suchindividuals."); Association of State Correctional Administrators, Policy Guidelines: HealthServices, reprinted in Medical Care of Prisoners and Detainees app. at 220 (Ciba Found.Symposium 16 (n.s.), 1973) ("Each facility should have available appropriate mental healthpersonnel or services to diagnose, prescribe and treat mental health problems."); Standards forHealth Services in Prisons, National Comm'n on Correctional Health Care P-24, at 28(1997)(important) (Staffing Levels) ("Written policies and defined procedures require, and actualpractice evidences, that there is a written staffing plan that assures a sufficient number of healthservices staff of varying types is available to provide adequate evaluation and treatment consistentwith contemporary standards of care."); id. (discussion) ("The number and types of health careprofessionals required at a facility depend upon the size of the facility, the types (medical,nursing, dental, mental health) and scope (outpatient, specialty care, inpatient) of servicesdelivered, the needs of the inmate population, and the organizational structure (e.g., hours ofservice, use of assistants, scheduling). Also, special consideration should be given to the numberof patients in segregated housing, since the more restricted inmates' movement is, the more demands there are on staff time. These factors should be addressed in the facility's health servicestaffing plan. It is important to ensure that there is sufficient physician time."); Standards forHealth Services in Jails, National Comm'n on Correctional Health Care P-23, at 29 (1996)American Ass'n of Correctional Psychologists, Standards for Psychological Services in Adult Jailsand Prisons, 7 Crim. Just. & Behav. 81, § 12, at 94 (1980) (essential) ("The ratio of staff toinmates is at least one full-time psychologist for every 200-250 prisoners. In specialized units(e.g., drug treatment) the minimally acceptable ratio is one full-time psychologist for every 100- 125 inmates. Additionally, staff shall reflect ethnic, racial, and lin[g]uistic characteristics ofclients, to the greatest degree possible."); American Psych. Ass'n, General Guidelines forProviders of Psychological Services, § 2.1.2, at 4 (1987) ("A psychological service unit strivesto include sufficient numbers of professional psychologists and support personnel to achieve itsgoals, objectives, and purposes."); Standard Minimum Rules for the Treatment of Prisoners:Resolution of the First United Nations Congress on the Prevention of Crime and the Treatment ofOffenders, E.S.C. Res. 663C, U.N. ESCOR, 24th Sess., Supp. No. 1, ¶ 49(1), U.N. Doc.A/CONF/611 (1955), amended by E.S.C. Res. 2076, U.N. ESCOR, 62d Sess., Supp. No. 1, at35, U.N. Doc. E/5988 (1977) (institutional personnel) ("So far as possible, the personnel shallinclude a sufficient number of specialists such as psychiatrists, psychologists, social workers,teachers and trade instructors."); American Psychiatric Ass'n, Guidelines for Psychiatric Servicesin Jails and Prisons, in Psychiatric Services in Jails and Prisons, Task Force Report 29,§ C.3.b(2) (jails) (1989) ("[Essential mental health services include] seven-day-a-week mentalhealth coverage (including at least three days with board-certified or board-eligiblepsychiatrist)."); id., § D.3.a(4) (prisons) ("[Required mental health modalities include] seven-day-a-week mental health coverage which includes 24 hour availability of consultation with apsychiatrist (Unless otherwise demonstrated as unnecessary, the presence of a psychiatrist on siteshould be at least once a week. Larger facilities or facilities with in-patient care will requireconsiderably more on-site psychiatric coverage.)."); National Comm'n on Correctional HealthCare P-20, at 23 (1992) ("It is recommended that there be at least one full-time-equivalentphysician in prisons with an average daily population of 750 or greater."); American Psych. As'n,General Guidelines for Providers of Psychological Services § 1.1, at 3 (1987) ("Eachpsychological service unit offering psychological services has available at least one professionalpsychologist and as many more professional psychologists as are necessary to assure the qualityof services offered.").

    See also Coleman v. Wilson, 912 F. Supp. 1282, 1995 WL 559109, *16 (E.D. Cal. 1995)(finding Eighth Amendment violation where Department of Corrections "is seriously andchronically understaffed in the area of mental health care"); Arnold on behalf of H.B. v. Lewis,803 F. Supp. 246 (D. Ariz.