MONTGOMERY — A schizophrenic and delusional Alabama Department of Corrections inmate eventually would kill another prisoner and threaten to kill a correctional officer.

But mental health workers within ADOC had deemed him as stabilized with a “mild” impairment, according to testimony and evidence in the federal trial over mental health care in the state’s prisons.

The number and percentage of inmates receiving mental health services in Alabama’s prisons has increased in recent years, as the overall prison population declines. But advocates and a federal judge say treatment isn’t reaching near as many prisoners as should be served and the treatment available is often insufficient. Some prison practices are detrimental to inmates’ mental health.

According to U.S. District Judge Myron Thompson’s late June ruling, the percentage of Alabama prisoners with mental illness is 14 to 15 percent, while the national average is 20 to 30 percent.

“There were experts who said more than 30 percent (need mental health care), but we find the judge’s conclusion to be well supported,” said James Tucker, director of the Alabama Disabilities Advocacy Program, one of the plaintiffs in the lawsuit filed in 2014.

And for those receiving care, it’s “wholly inadequate,” Tucker said.

Thompson agreed.

“In addition to delaying treatment or leaving mental-health symptoms untreated, ADOC’s broken referral process has contributed to the phenomenon of prisoners engaging in self-harm or other destructive behavior in order to get attention of mental-health staff,” the ruling said.

Thompson ruled in favor of inmates but did not order specific changes and directed the state to meet with inmates' lawyers to work on reforms.

The plaintiffs and ADOC have until Sept. 1 to reach an agreement on how to fix the issues outlined in Thompson's order. If they don't, a remediation trial is set for Nov. 15.

Corrections spokesman Bob Horton in an email Friday said because of the confidentiality of the mediation, the department was unable to comment on the ongoing process.

About the possible 30 percent of inmates who may need care, Horton said notwithstanding the national average, “More importantly we want to ensure all inmates requiring care are identified and treated.”

Based on trial testimony from defendants and ADOC officials, the court found seven areas of inadequacy, including: the identification and classification of prisoners with mental illness; a lack of mental-health care units; crisis and suicide prevention; the use of disciplinary actions in response to symptoms of mental illness; and the use of segregation for mentally ill prisoners.

ADOC has an unacceptable practice of disciplining mentally ill prisoners for behavior that stems from their mental illnesses and does so without adequate regard for the disciplinary sanctions’ impact on mental health, Thompson found.

“(Prisons) deal with issues created by mental illness as disciplinary problems and treat them as disciplinary problems,” said Jimmy Walsh, a Birmingham attorney and president of the Alabama chapter of the National Alliance on Mental Illness. “It’s easier and cheaper.”

Thompson’s ruling said three conditions contribute to all the deficiencies in ADOC’s treatment of mentally ill prisoners: understaffing of mental-health care providers; understaffing of correctional officers; and overcrowding.

A 2013 audit of Donaldson Correctional Facility in Jefferson County showed mental-health staff members were manning laundry and showers instead of providing health care because there were not enough correctional officers to perform those duties.

Staff shortages across ADOC have become a perennial topic in the Alabama Statehouse as lawmakers consider budget needs and proposals for new, more efficient prisons. According to ADOC’s most recent monthly report, its major facilities have 44 percent of the correctional officers they need.

But Thompson’s ruling questions how that number is figured, saying a staffing analysis hasn’t been done in the past decade to determine exactly how many officers are needed to keep officers and prisoners safe.

“… ADOC’s own reports have been relying on authorized position numbers based on rudimentary ratios that do not take into consideration the actual layouts of facilities.”

Horton said the department intends to obtain an outside expert to evaluate current staffing levels and any necessary increases, which it believes can be used to resolve the issues in the court’s order.

Understaffed contractor

For more than a decade, ADOC has contracted its mental health care out to MHM Correctional Services Inc.

But MHM program Director Teresa Houser told the court MHM staffing shortages make it difficult to “do the work required under the contract,” and the current caseload for 50 MHM staff members does not meet an “acceptable standard.”

The caseload per MHM provider has been increasing since 2008, to nearly twice what they should be, largely because of an increasing number of prisoners with mental-health needs; multiple budget cuts; and ADOC’s refusal to increase the authorized number of mental-health staff positions despite repeated requests from MHM, the ruling said.

MHM’s documents showed that between 2008 and 2016, the mental-health caseload increased by 25 percent across all ADOC facilities. Meanwhile, ADOC officials admitted MHM has been understaffed since 2013.

As of early July, MHM had been paid $12.1 million for the fiscal year that ends in late September, according to state records. In fiscal 2016, it received just over $12 million; in 2015, it was paid $10 million.

State tax dollars, allocated by lawmakers each year, make up most of ADOC’s funding. In 2008, it was $353.7 million. While funding did decrease in the early part of this decade, next year, ADOC will receive $413 million.

In 2013, citing budget cuts, MHM’s contract was renegotiated “to reduce the previously agreed-upon minimum required staffing, cutting close to 20 full-time equivalent positions.”

Other issues

Three of the state’s 15 major prisons serve as “treatment hubs” for mental-health services, with Bullock Correctional Facility, Donaldson and Julia Tutwiler Prison for Women serving the most severely mentally ill.

Thompson’s 300-page ruling showed other serious concerns about mental health care within ADOC:

• Because they have a limited number of cells to work with, prisons gamble on who to put in them and frequently discount prisoners’ threats of self-harm and suicide.

• For years, ADOC has failed to respond reasonably to problems. Despite knowledge of serious and widespread deficiencies, it has failed to remedy known problems and exercised very little oversight of MHM.

• The majority of suicides are committed by prisoners not on the mental-health caseload, meaning many of the prisoners’ needs were never identified through the intake or referral process, and no intervention happened before their deaths.

• While ADOC’s contract with MHM specifies all mental health providers must be licensed, only four out of 47 were licensed as of February 2016.

“The department is evaluating a variety of options to resolving the court’s concerns over the use of unlicensed mental-health care professionals,” Horton said.

Meanwhile, according to the ruling, multiple experts testified that during site visits, they were not allowed to enter certain parts of prisons because officials could not guarantee their safety.

Ward, the lawmaker, has estimated correcting ADOC’s mental-illness treatment will cost the state $25 million to $30 million.

“Any way you’re going to do this, you’re going to have to open the General Fund budget up,” Ward said. “This is not something you can borrow or bond your way out of.”

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