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(1) (a) (i) 1) a)I.A.1.a.(1)(a)i)a)#|V ) `(CG TimesScalable&&m P7&P,xA`&UniversScalableXX~xP7XP<6X9`("Courier NewTTeXXx6X@DQX@%2A`ArialTTTTe&&Q2PQ&P%2A`ArialTTTTeI2PQP%2A`ArialTTTTeB2PQP:6X9`("Courier NewTTe6X@DQ@<6X9`("Courier NewTTeZ6X@DQ@:6X9`("Courier NewTTe6X@DQ@96X9`("Courier NewTTe& i6X@DQ&@86X9`("Courier NewTTewK6X@DQ@"2A`ArialTTTTe>2PQP,xA`&UniversScalablexP7P* `(CG TimesScalableXXw P7XP(~R$ dHP LaserJet III (2nd Floor),,,,,,0{-c{X-ԋU ~R!  _ C XdX&CXXXdENTERFORCCX P CXXHCUBLICCCX R CXXHCEPRESENTATION  ?=' xxExx? x 246WalnutStreet((=(#MentalHealthProtection&AdvocacyProject X Newton,MA02460(#(#h(#   (#(#h(#\(#617/9650776V(#617/9646560(TTY)V(#617/9280971(FAX)    XdX%&XdXXXd@1February1,1999  THELEGALRIGHTSOFPRISONERSWITHMENTALDISORDERS       Thereareatleast1.8millionpeopleincarceratedinprisonsorjailsintheUnitedStates,andthenumbercontinuestoincreaseeachyear.Theincidenceofmentaldisordersamongprisonersissubstantiallyhigherthanitisinthecommunity,withapproximatelytenpercentofprisonerssufferingfromamajormentalillness,definedasschizophrenia,bipolardisorder,ormajordepression.Indeed,theLosAngelesCountyJailhasbeencalledthelargestdefactomental h  hospitalintheworld.Additionally,atleast12%ofallinmateshaveadevelopmentaldisability.  Despitethetremendousdemandformentalhealthtreatment,theavailableservicesinmany,ifnotmost,prisonsandjailsarewoefullyinadequate.InthewordsofStuart_Grassian_,aHarvardMedicalSchoolpsychiatristwhohasservedasanexpertwitnessinmanyprisonmental  healthcases,"I'veseenpeoplewhoarehorriblyill,eatingtheirownfeces,eatingpartsoftheirbody,howlingdayandnightandit'signored,like'whocares?'Youthinkitbelongstosomeothercentury,butyougointotheprisonandyouthinkyou'rebackinsomemedievaltorturechamber.Theprisonhasbecomethisplacethat'shiddenandsecretandit'sreallyawful."Giventhelackofresourcesavailabletotreatprisonerswithmentalillness,itisnotsurprisingthatthesuiciderateinprisonsandjailsismuchhigherthaninthecommunityasawhole.Norissuicidetheonlyrisk.Prisonerswithuntreatedmentalillnessarealsovulnerabletovictimizationbyotherinmates,mayposeathreatofassaulttocorrectionalofficersandstaff,andcanseriouslydisrupttheprisonroutine.Theyarealsolikelytofacediscriminationinclassification,accesstorehabilitativeprograms,andparole. ConstitutionalPrinciples  '(#-   Sincethereislittlepublicorpoliticalsupportforqualitymentalhealthcareforoffenderswithmentalillness,prisonershavebeenalmostentirelydependentonthecourtsforprotectionoftheirrighttotreatment.Dozensofclassactionlawsuitshavesuccessfullyattackedtheoverallqualityofcareincorrectionalinstitutionsacrossthecountry.Seee.g.,Colemanv.Wilson,912 .h)5 F.Supp.1282(E.D.Cal.1995);Austinv.PennsylvaniaDept.ofCorrections,876F.Supp..1437  (E.D.Pa.1995);Dunnv.__Voinovich_,CaseNo.C1-93-0166(S.D.Ohio1995);Madridv.Gomez, @ 889F.Supp.1146,1280(N.D.Calif.1995);Langleyv._Coughlin_,715F.Supp.522(_S.D.N.Y._   1989),_aff'd_888F.2d252(2dCir.1989). `    ThestartingpointforanunderstandingoftheconstitutionalprinciplesunderlyingtheclaimofinmatestomentalhealthservicesisEstellev.Gamble,429U.S.97(1996),wheretheSupreme    CourtheldthattheEighthAmendment'sprohibitionagainstcruelandunusualpunishmentendowsallinmateswitharighttomedicalcare.Specifically,thecourtruledthatprisonofficialsmaynotexhibit"deliberateindifference"tothe"seriousmedicalneeds"ofinmates.Thus,anEighthAmendmentclaimhastwobasicelements:anobjectivecomponent,theexistenceofa"seriousmedicalneed";andasubjective,orstateofmind,component,namelythataprisonofficialwas"deliberatelyindifferent"totheneedfortreatment.Thecaseselaboratingtheconstitutionalrequirementsinthisarea,however,areoftenmurkyandinconsistent.Forexample,courtshaveconsiderabledifficultyindecidingwhatmentalhealthneedsare"serious"enoughtomandatetreatment.CompareSteelev.Shah,87F.3d1266,1267(11thCir.1996)(prisonerwho"suffered  frominsomnia,anxiety,andvariousbodilypains"and"feelingsofhelplessness"statedaclaimundertheEighthAmendment)with_Doty_Ԁv.Countyof_Lassen_,37F.3d540(9thCir.1994)   (femaleprisonerwhoexperiencednausea,shakes,headache,sleeplessness,anddepressedappetitesufferedmerelyfrom"mild,stressrelatedailments"and"routinediscomfort"didnothavea"serious"medicalneed).Generally,however,prisonershavearighttopsychologicalorpsychiatrictreatmentundertheEighthAmendmentifaphysicianorotherhealthcareprovider"concludeswithreasonablemedicalcertainty(1)thattheprisoner'ssymptomsevidenceaseriousdiseaseorinjury;(2)thatsuchdiseaseorinjuryiscurableormaybesubstantiallyalleviated;and(3)thatthepotentialforharmtotheprisonerbyreasonofdelayorthedenialofcarewouldbesubstantial."_Bowring_Ԁv.Godwin,551F.2d44(4thCir.1977).Thus,milddepressionandanxiety 0*%0 associatedwiththestressoftheprisonexperiencewillnotberegardedasa"serious,"whileanyconditionthatisdiagnosedbyadoctorasmandatingtreatmentmustreceiveprofessionalattention. P-(4   Discerningwhetherornotprisonofficialshavedemonstratedtherequisite"deliberateindifference"canbesimilarlyconfusing.Itisnotenoughthatprisonofficialsexercisedpoorjudgment,orthattheywerenegligentorevengrosslynegligent;rathertheinmatemustshowthattheprisonofficialwasatleastreckless,andrecklessinthecriminalsense,meaningthatheorshehadactualknowledgeofaconditionthatrequiredtreatment.Farmerv.Brennan,511U.S.825,  @ 828829(1994).Thisdoesnotmeanthatprisonofficialsmayshieldthemselvesfromliabilitybydeliberatelyremainingignorantabouttheneedfortreatment.Theywillstillbeheldaccountableiftheydeliberatelydisregardaknownrisk,eveniftheyareignorantofthedetailsofaparticularinmate'ssituation. 0   BasicComponentsofaPrisonMentalHealthSystem     Whiletheremaybecontroversyaboutwhetheraspecificinmatehasreceivedconstitutionallyacceptablecare,thecourtshaveestablishedaclearsetofminimumrequirementsforanadequatesystemofprisonmentalhealthcare.Further,anumberofprofessionalorganizations,suchastheNationalCommissiononCorrectionalHealthCareandtheAmericanPsychiatricAssociation,havepromulgatedstandardsgoverningmentalhealthservicesinprisonsandjails.Seee.g.,National_Comm'n_ԀonCorrectionalHealthCare,StandardsforHealthServices  p inPrisons(1997).Althoughcourtsarefondofsayingthattheprofessionalstandardsmaywell   exceedtheconstitutionalfloor,theyoftenutilizesuchstandards,bothtoevaluatethequalityofmentalhealthcareandtodeviseremediesforconditionsfoundtobeunlawful.   $   Theessentialcomponentsofaprisonmentalhealthsystemaresetforthbelow.Foramoredetailedaccount,includingcitationstoprofessionalstandardsandcases,consulttheSummaryofProfessionalStandardsGoverningMentalHealthServicesinPrisonsandJailspublishedby_ATTAC_Ԁin1998.1.  ScreeningandEvaluations h)$/   Thefirstrequirementisthateveryinmatebescreeneduponadmissioninordertoidentify *H&1 thosewithmentalillnessordevelopmentaldisabilities.Thisgenerallyentailsastandardizedsetofquestionsandobservationsbyspeciallytrainedstaff.The_screenings_Ԁmustbeconductedina .h)5 confidentialsetting.Theremustbeamechanismtoensurethatallinmatesidentifiedaspossiblysufferingfromamentaldisorderarepromptlyreferredforacomprehensivementalhealthevaluationandanynecessarytreatment.Thethresholdforreferralforservicesmustbelow,bothuponadmissionandlater,sinceitiseasyformentallyillinmatestoescapenoticeintheprisonenvironmentsolongastheydonotengageinegregiouslybizarrebehavior.Inaddition,inmatesmustbemonitoredthroughouttheirincarcerationintheeventtheydevelopsignsandsymptomsofmentalillness.Itiscrucialthatinmateswhoareinsegregationorsolitaryconfinementbeassessedbymentalhealthstaffatleastonceperweek.Itisalsovitalthattheinstitutionhaveaprogramtoidentifyandsupervisesuicidalinmatesandthoseincrisis.2.  TreatmentModalities   h     Correctionalinstitutionsmustprovidearangeofmeaningfultreatmentmodalitiestoinmatesidentifiedashavingamentaldisorder.Althoughmanyprisonsandjailssimplyconfinementallyillinmatestosegregationunitswheretheycanbecloselysupervised,thisisnotacceptable.Theinstitutionmustmakeavailablepsychotropicmedicationifneeded.Psychotropicmedicationmustbeprescribedonlybyapsychiatristandinaccordancewithcontemporarymedicalstandards.Psychiatristsorphysiciansshouldmonitorallinmatesonpsychotropicmedicationsandreevaluatethepatientbeforerenewingtheprescription.Further,theprisonformularyshouldcontainarangeofpsychotropicmedications.  Medicationalone,however,isnotsufficient.Itmustbepartofanoverallprogramoftherapy,includingindividualandgrouptherapywhereappropriate,aswellascrisisinterventionservices.Eachinmatewithachronicmentaldisordershouldalsohaveanindividualizedtreatmentplan.Inaddition,thefacilitymustprovidequalifiedinterpreterstoensurethatnonEnglishspeakinginmateshaveaccesstomentalhealthservices.Further,noinmatewithahistoryofmentalillnessshouldbedisciplinedwithoutfirstconsultingwithmentalhealthstaff.3.  QualifiedMentalHealthStaff 0*%0   Itisabsolutelyessentialthattheinstitutionhavesufficientnumbersofqualifiedandtrainedstafftoprovidetreatmentconsistentwithcontemporarystandardsofcare.Thismeansthefacility P-(4 musthaveanadequatenumberofpsychiatrists,psychologists,andothermentalhealthprofessionals,eitheronsiteoroncall,toprovideallnecessaryservices.Althoughtherearenoclearstandardsquantifyinganappropriatenumberofmentalhealthprofessionals,expertsgenerallyinsistthatthecaseloadofaprisonpsychiatristshouldbenomorethan125150,andjailpsychiatristsshouldnothaveacaseloadthatexceeds75100.Oneoftheworstconsequencesofinadequatestaffingisthatonlythosementallyillprisonerswhoexhibitespeciallybizarrebehavior,orwhoareassaultiveanddisruptive,arelikelytoreceiveanytreatmentatall.Eventhoughtheirillnessmaybeequallysevere,thosewhosufferquietlygounnoticedandunserved.Thisproblemisexacerbatedbythecommonfailuretoprovidesufficienttrainingtocorrectionalofficersconcerningthesignsandsymptomsofmentalillness.4.  SpecialNeedsUnitsandInpatientHospitalization P   Likeindividualssufferingfrommentalillnessinthecommunity,inmatesmaysometimesneedspecialhousingseparatefromthegeneralprisonpopulationtoreceivemoreintensivetreatmentandsupervision.Thismayrangefromadaytreatmentprogramwithintheprison,toacrisisunitforacutelypsychoticorsuicidalinmateswhodoesnotrequireinpatienthospitalization,toanintermediatelevelresidentialtreatmentunitforthosewhoseleveloffunctioningmakesthemvulnerabletoabusefromotherinmates,aretoodisruptiveforplacementinthegeneralpopulation,orwhoneedsubstantialtherapeuticservices.Sincesometimesnothingshortofintensiveinpatienthospitalizationisadequateforaninmatewhohas_decompensated_,theinstitutionmustalsohaveaproceduretotransferacutelymentallyillprisonerstoahospitalsetting.5.  AccurateMentalHealthRecords % *   Mentalhealthtreatmentrecordsmustbeaccurate,complete,uptodate,andwellorganized.Thefacilityshouldalsoobtainpastpsychiatricrecordswheneverpossible.Theinmate'smentalhealthrecordsmustbekeptconfidentialbymaintainingthemseparatelyfromotherrecords.Whenaninmateistransferredtoanotherinstitution,hisrecordsmustbesenttothereceivingfacilitytoinsurecontinuityofcare.   P-(4 6.  DischargePlanning    Sincemostmentallyillinmatesareeventuallyreleasedbacktotheircommunities,itisvitalthatthefacilitymakeanefforttoensurecontinuityofcareafterrelease.Thismaymeanprovidingtheinmatewithamedicationprescription,aswellasarrangingforfollowupservicesincommunitymentalhealthcenters.7.  QualityAssuranceProgram      Theinstitutionmusthaveaqualityassuranceplantoassurethatinmatesreceivecompetentcare.Thisshouldincludestudiesofutilizationpatternsandclinicaloutcomesinthefacilityasawhole,aswellasanalysisoftheclinicalrecordofindividualprisoners.  Althoughmanyprisonsandjailshavecarefullydraftedpoliciesandproceduresdesignedtomeettheirconstitutionalobligationsregardingmentalhealthcare,thereisoftenawidegulfbetweenwhatexistsonpaperandtheservicesthatareactuallyavailable.Thequalityoftheservicesandthephysicalplantisalsooftensubstandard.Thus,thereisnosubstituteforthoroughfactualinvestigationinordertomakeanassessmentoftheadequacyofthementalhealthservicesinanyjailorprison.__#&p%XXd#