Braggs v. Dunn

LIABILITY OPINION AND ORDER AS TO PHASE 2A EIGHTH AMENDMENT CLAIM

Myron H. Thompson, UNITED STATES DISTRICT JUDGE

I. INTRODUCTION 1180

II. PROCEDURAL BACKGROUND 1180

III. FACTUAL BACKGROUND 1181

A. ADOC Facilities and Organizational Structure 1181

B. MHM Organizational Structure 1183

C. Summary of Factual Findings 1184

1. Fact Witnesses 1184

2. Expert Witnesses 1186

IV. EIGHTH AMENDMENT LEGAL STANDARD 1188

V.FINDINGS OF FACT AND CONCLUSIONS OF LAW 1189

A. Serious Mental-Health Needs 1189

B. Actual Harm and Substantial Risks of Serious Harm Posed by Inadequate Care 1191

1. Contributing Conditions 1193

a. Overcrowding 1193

b. Mental-Health Understaffing 1194

c. Correctional Understaffing 1197

2. Identification and Classification of Prisoners’ Mental-Health Needs 1201

a. Inadequate Intake Process 1201

b. Inadequate Referral Process 1203

c. Inadequate Classification of Mental-Health Needs 1204

d. Inadequate Utilization of Mental-Health Units 1205

3. Inadequate Treatment Planning 1206

4. Inadequate Psychotherapy 1208

5. Inadequate Inpatient Care 1212

a. Improper Use of Mental-Health Units 1212

b. Inadequate Out-of-Cell Time and Programming 1213

c. Lack of Hospital-Level Care 1217

6. Inadequate Suicide Prevention and Crisis Care 1218

a. Failure to Provide Crisis Care, to Those Who Need It 1221

b. Placement of Prisoners in Crisis in Dangerous and Harmful Settings 1224

c. Inadequate Treatment in Crisis Care 1225

d. Unsafe Crisis Cells 1226

e. Inadequate Monitoring of Suicidal Prisoners 1229

f. Inappropriate Release from Suicide Watch and Inadequate Follow-up 1230

7. Inappropriate Use of Disciplinary Actions 1231

*1180 8. Inappropriate Placement and Inadequate Treatment in Segregation 1235

a. Background on Segregation 1236

i. Consensus among Correctional and Mental-Health Professionals on Segregation ' 1236

ii. ADOC’s Segregation Units 1238

b. ADOC’s Segregation of Mentally Ill Prisoners 1240

i. ADOC’s Segregation-Placement Practices 1240

ii. Treatment and Monitoring in Segregation Units 1242

c. Segregation of Prisoners with Serious Mental Illness 1245

9. Tutwiler 1247

10. Other Issues 1249

C. Deliberate Indifference 1250

1. ADOC’s Knowledge of Harm and Risk of Harm 1252

2. ADOC’s Disregard of Harm and Risk of Harm 1255

a. ADOC’s Failure to Exercise Oversight of the Provision of Mental-Health Care 1257

b. ADOC’s Unreasonable Responses to Identified Deficiencies 1260

D. Ongoing Violation 1262 .

E. Ex parte Young Defenses 1265

VI. CONCLUSION 1267

I. INTRODUCTION

The plaintiffs in this phase of this class-action lawsuit are a group of seriously mentally ill state prisoners and the Alabama Disabilities Advocacy Program (ADAP), which represents mentally ill prisoners in Alabama. The defendants are the Commissioner of the Alabama Department of Corrections (ADOC), Jefferson Dunn, and the Associate Commissioner of Health Services, Ruth Naglich, who are sued only in their official capacities. The plaintiffs assert that the State of Alabama provides constitutionally inadequate mental-health care in prison facilities and seek injunctive and declaratory relief. They rely on the Eighth Amendment, made applicable to the States by the Fourteenth Amendment and as enforced through 42 U.S.C. § 1983 . Jurisdiction is proper under 28 U.S.C. § 1331 (federal question) and § 1343(a)(3) (civil rights).

After a lengthy trial, this claim is now before the court for resolution on the merits. Upon consideration of the evidence and arguments, the court finds for the plaintiffs in substantial part. Surprisingly, the evidence from both sides (including testimony from Commissioner Dunn and Associate Commissioner Naglich as well as that of all experts) extensively and materially supported the plaintiffs’ claim.

II.PROCEDURAL BACKGROUND

This extremely complex case has been split into three phases: Phase 1 involved claims under Title II of the Americans with Disabilities Act (ADA), codified at 42 U.S.C. § 12131 et seq., and § 504 of the Rehabilitation Act, codified at 29 U.S.C. § 794 , claiming discrimination on the basis of physical disabilities and failure to accommodate those disabilities. The parties settled Phase 1. See Dunn v. Dunn, 318 F.R.D. 652 (M.D. Ala. 2016) (Thompson, J.). Phase 2A involves Eighth Amendment, ADA, Rehabilitation Act, and due-process claims regarding mental-health care. The parties settled the Phase 2A ADA and Rehabilitation Act claim. The due-process claims are pending before the court for settlement approval. 1 Phase 2B will focus *1181 on medical-care and dental-care claims under the Eighth Amendment,

This opinion resolves only the Phase 2A Eighth Amendment claim of inadequate mental-health care. 2 The court has certified a Phase 2A plaintiff class consisting of all persons with a serious mental illness who are, or will be, confined within ADOC’s facilities, excluding Tutwiler Prison for Women and the work-release centers. See Braggs v. Dunn, 317 F.R.D. 634 (M.D. Ala. 2016) (Thompson, J.). While mentally ill prisoners at Tutwiler are not part of the class, ADAP, as Alabama’s designated protection and advocacy organization for the mentally ill, brought claims on their behalf A seven-week trial followed.

III. FACTUAL BACKGROUND

Mental-health care in this opinion refers to screening, treatment, and monitoring of mental illnesses, as well as ADOC’s policies and practices regarding mentally ill prisoners, including decisions on disciplinary sanctions and housing placements. 3 Before diving in to the details of weeks’ worth of testimony and thousands of pages of documentary evidence regarding mental-health care within ADOC, the court pauses to provide some background information on ADOC and its mental-health contractor, as well as a summary of the factual findings.

A. ADOC Facilities and Organizational Structure

ADOC runs 15 major facilities (14 for men and the Tutwiler Prison for Women) and houses around 19,500 prisoners in its major facilities. 4 Approximately 3,400 prisoners are on the mental-health caseload, meaning that they receive some type of mental-health treatment, such as counseling or psychotropic medications.

MAJOR ADOC FACILITIES 5

*1182 Facility Location ¡Population

Bibb Brent 1847

Bullock Union Springs 1522

Donaldson Bessemer 1474

Draper Elmore 1144

Easterling. Clio 1457

Elmore Elmore 1186

Fountain Atmore 1242

Hamilton Hamilton 275

Holman Atmore • 941

Kilby Mt. Meigs 1126

Limestone Harvest 2214

St. Clair Springville 975

Staton Elmore 1382

Ventress Clayton 1254

Tutwiler Wetumpka 880

Three of the major facilities, Bullock, Donaldson, and Tutwiler, serve as ‘treatment hubs’ for mental-health services, containing a residential treatment unit (RTU) and/or a stabilization unit (SU). These two types of units, together referred to as ‘mental-health units’ or ‘inpatient-care units,’ house and treat the most severely mentally ill prisoners. The rest of those on the mental-health caseload receive their care through outpatient services: they live in a unit that is not focused on treatment and ordinarily must go to a different part of the prison to see a mental-health provider.

Under the administrative regulations governing ADOC’s mental-health care, RTUs are for mental-health patients who suffer from “moderate impairment in mental health functioning” that puts them at risk in a general-population setting. Joint Ex. 107, Admin. Reg. § 613-2 (doc. no. 1038-130). RTUs are intended to provide a therapeutic environment to mentally ill patients and to help them develop coping skills necessary for placement in general population. RTUs can be ‘closed,’ meaning that each patient lives in an individual cell with little time spent outside the cell; ‘semi-closed,’ meaning that the patient still stays in an individual cell but is let out of *1183 the cell more often; or ‘open,’ meaning that the patient lives in an open dormitory with other RTU patients. ■

SUs are for patients who are suffering from acute mental-health problems — such as acute psychosis or other conditions causing an ■ acute risk of self-harm — and have not been stabilized through other interventions. SUs are intended to stabilize the patient as. quickly as possible so that the patient can return to a less restrictive environment. All SU patients are housed in individual cells.

Altogether, the two male treatment hubs have 346 RTU beds and 30 SU beds: Bullock has 250 RTU beds and a 30-bed SU for male prisoners, and Donaldson has an additional 96-bed RTU. Tutwiler has 30 RTU beds and eight SU beds for women. These units provide services to about 2 % of ADOC’s overall population.

ADOC is headed by Commissioner Dunn. Associate Commissioner for Health Services Naglich heads the Office of Health Services (OHS), which is responsible for overseeing the provision of medical and mental-health care to prisoners. ADOC uses private contractors to deliver medical and mental-health care services to prisoners. Under the mental-health contract with a third-party vendor, OHS has access to the contractor’s internal documents and records, and the contractor is required to send certain reports, such as monthly operating reports and annual contract-compliance reports, to OHS. The only OHS staff member with mental-health expertise is Dr. David Tytell, the chief clinical psychologist. Dr, Tytell serves as the main liaison between the mental-health contractor and ADOC, and communicates with the contractor’s program director at least weekly. ADOC also directly employs ‘psychological associates,’ who are counselors responsible for conducting certain psychological tests at intake and for providing group sessions and classes for non-mentally ill prisoners. They report to their respective facilities’ wardens, rather than OHS or the mental-health contractor.

B. MHM Organizational Structure

MHM Correctional Services, Inc. is ADOC’s contractor for mental-health care. MHM is a for-profit corporation that provides medical and mental-health services to correctional facilities across the country.

MHM’s regional office in Alabama is headed by its program director Teresa Houser. She serves as the main liaison between ADOC and MHM- Dr. Robert Hunter, a psychiatrist who serves as the medical director for the Alabama regional office, is charged with supervising psychiatrists and certified registered nurse practitioners (CRNP) stationed at various ADOC facilities. Both Houser and Hunter communicate frequently with ADOC officials, including Associate Commissioner Naglich and Dr. Tytell.

MHM employs a variety of administrative and clinical personnel to fulfill its contract with ADOC. In its regional office, Houser supervises various administrators and managers, such as the continuous quality improvement (CQI) manager, who conducts informal audits of MHM’s performance, and the chief psychologist, who supervises psychologists and conducts training for MHM employees. At the facility level, MHM employs site administrators to provide administrative oversight; these administrators are counselors by training. MHM also employs approximately 45 full-time ‘mental-health professionals’ (MHPs), who are masters-level mental-health counselors, at prisons across the State. As of December 2016, MHM employed four psychiatrists and eight CRNPs in Alabama; these providers are qualified to diagnose mental illnesses, prescribe psychotropic medication, and provide psychotherapy across multiple facilities. MHM also employs three psychologists and three.regis *1184 tered nurses (RNs) for the entire State. The RNs are stationed at the three treatment hubs, Bullock, Donaldson, and Tut-wiler; they administer medication, provide crisis intervention, and supervise the licensed practical nurses (LPNs) at their facilities. MHM employs approximately 40 LPNs, individuals with 12 to Í5 months of health-care training. The LPNs are responsible for conducting mental-health intake at Kilby and Tutwiler, monitoring medication compliance, maintaining medication records, and conducting side-effects monitoring tests for psychotropic medications. While the LPNs stationed in the mental-health treatment units are supervised by the on-site RN, at all other places, including at intake screening, LPNs have no on-site supervision. Lastly, MHM employs six to eight activity technicians, who organize or assist in therapeutic, social, and recreational activities for patients in mental-health units.

C.- Summary of Factual Findings

1. Fact Witnesses

Over the course of seven weeks, the court heard testimony as to whether ADOC’s mental-health care violates mentally ill prisoners’ constitutional rights. The trial opened with the testimony of prisoner Jamie Wallace, who suffered from severe mental illnesses, intellectual disability, and substantial physical disabilities. Wallace stated that he had tried to kill himself many times, showed the court the scars on arms’ where he made repeated attempts, and complained that he had not received sufficient treatment for his illness. Because of his mental illness, he became so agitated during his testimony that the court had to recess and reconvene to hear his testimony in the quiet of the chambers library and then coax him into completing his testimony as if he were a fearful child. The court was extremely concerned, by what it had seen and heard from this plaintiff, about the fragility of his mental health. At the end of Wallace’s testimony and out of his presence, the court informed the attorneys for both sides that it wanted a full .report on his mental condition and the steps that were being taken to address that condition. Unfortunately, and most tragically, ten days after Wallace testified, he killed himself by hanging. Because it appeared that adequate measures may not have been put in place to prevent Wallace’s suicide, the court put the parties into mediation to attempt to come up with immediate, interim procedures to prevent future prisoner suicides. The parties eventually came up with such procedures. Without question, Wallace’s testimony and the tragic event that followed darkly draped all the subsequent testimony like a pall.

The plaintiffs’ case then proceeded with testimony from Commissioner Dunn, who aptly described the prison system as wrestling with a “two-headed monster”: overcrowding and understaffing. Dunn Testimony at 26. The court also heard from Associate Commissioner Naglich and MHM’s program director Houser, for whom overcrowding and understaffing (both as to correctional staff, as noted by Dunn, and mental-health staff) were a mantra. They, with admirable candor, as with many other fact witnesses and the experts from both sides, essentially agreed that the staffing shortages, combined with persistent and significant overcrowding, contribute to serious systemic deficiencies in the delivery of mental-health care.

The inadequacies in the mental-health care system start at the door, with intake screening for prisoners who need mental-health care. ADOC boasts one of the lowest mental-illness prevalence rates among correctional systems in the country. But this is not because Alabama has fewer mentally ill prisoners than the rest of the country or the best mental-health care sys *1185 tem for its prisoners; rather, according to experts from both sides, this is because a substantial number — likely thousands — of prisoners with mental illness are missed at intake and referrals for evaluation and treatment are neglected. As a result, many ADOC prisoners who need mental-health care go untreated.

Even when identified, mentally ill prisoners receive significantly inadequate care. Mental-health and correctional staffing shortages drive inadequate treatment. Individual and group counseling sessions are delayed or canceled due to shortages of counselors and correctional officers to escort prisoners to the sessions and to provide security. As a result, mental-health staff often have to resort to cell-side contacts, which cannot be considered substitutes for meaningful, confidential, out-of-cell appointments. Treatment planning is often pro forma and not individualized and fails to provide a meaningful and consistent course of treatment. Mental-health units intended as a therapeutic environment for the most severely ill prisoners operate like segregation units, with little counseling, therapeutic programming, or out-of-cell time. ADOC does not provide hospital-level care for those who need it.

ADOC also fails to provide adequate care to prisoners expressing suicidality and undergoing mental-health crises. Mental-health staff fail to use appropriate risk-assessment tools to determine suicide risk. ADOC has an insufficient number of crisis, or ‘suicide-watch,’ cells — special cells for the protection of suicidal prisoners. Because they have a limited number of cells to work with, they gamble on which prisoners to put in them and frequently discount prisoners’ threats of self-harm and suicide. The insufficient number of crisis cells also results in the use of unsafe rooms such as shift offices to house suicidal prisoners. The suicide-watch cells that do exist are dangerous: visibility into many of the cells is poor, making it difficult to monitor; many cells have tie-off points for ligatures that can be used for suicide attempts; dangerous items used for inflicting self-injury are often found. Prisoners in these cells receive less contact with and less monitoring by providers than the acuity of their condition demands. When they are released to general population or segregation, prisoners receive inadequate follow-up.

ADOC’s segregation practices inflict further harm on prisoners suffering from inadequate mental-health care. Due to the effects of isolation, placement in segregation endangers mentally ill prisoners, and the risk of harm increases with the length of isolation and the severity of their mental illness. This danger is compounded by the limited access to mental-health care and monitoring available within ADOC’s segregation units and dangerous conditions inside the cells. Despite these dangers, ADOC does not have a meaningful mechanism that prevents mentally ill prisoners from being placed in segregation for lengthy periods of time. Moreover, many mentally ill prisoners land in segregation due to symptoms of mental illness. This combination of conditions is often deadly: most suicides in ADOC occur in segregation.

For years, ADOC has failed to respond reasonably to these problems. Despite knowledge of serious and widespread deficiencies, it has failed to remedy known problems and exercised very little oversight of its mental-health care contractor. Associate Commissioner Naglich, who is in charge of contract monitoring, admitted that she has been aware of the contractor’s deficient performance and inadequate quality-control process; however, she does not monitor the contractor to ensure that it provides minimally adequate care. Moreover, ADOC officials admitted on the stand *1186 that they have done little to nothing to fix problems on the ground, despite their knowledge that those problems may be putting lives at risk.

The psychological and sometimes physical harm arising from these systemic deficiencies is palpable. Unidentified and. under-treated mental illness causes needless pain and suffering in the form of persistent or worsening symptoms, decompensation, 6 self-injurious behavior, and suicide. The skyrocketing suicide rate within ADOC in the last two years is a testament to the concrete harm that inadequate mental-health care has already inflicted on mentally ill prisoners.

In fact, as explained earlier, the court had a close encounter with one of the tragic consequences of inadequate mental-health care during the trial. Over the course of the trial, two prisoners committed suicide, one of whom was named plaintiff Jamie Wallace. Prior to his suicide, defendants’ expert, Dr. Patterson, concluded based on a review of Wallace’s medical records'that the care he had received was inadequate. Dr. Haney, a correctional mental-health care expert, met Wallace months before his death, while he was housed in a residential treatment unit, and in his report expressed serious concerns about the care he was receiving, 7 Wallace’s case was emblematic of multiple systemic deficiencies. Wallace testified, and his records reflected, that mental-health staff did not proyide much in the way of consistent psychotherapeutic treatment, which is distinct from medications administered by nurses and cursory ‘check-ins’ with staff. MHM clinicians recommended that he be transferred to a mental-health hospital, but ADOC failed to do so. His psychiatrist at the time of his death testified that the medically appropriate combination of supervised out-of-cell time and close monitoring when he was in his cell was unavailable due to a shortage of correctional officers. As a result, Wallace was left alone for days in an isolated cell in a treatment unit, where he- had enough time to tie a sheet unnoticed; because his cell, was not suicide-proof, he was able. to find a tie-off point from which to hang himself.

The case of Jamie Wallace is powerful evidence of the real, concrete, and terribly permanent harms that woefully inadequate mental-health care inflicts on mentally ill prisoners in Alabama. Without systemic changes that address these pervasive and grave deficiencies, mentally ill prisoners in ADOC, whose symptoms are no less real than Wallace’s, will continue to suffer.

2. Expert Witnesses.

Plaintiffs and defendants presented five experts in the correctional mental health and correctional administration fields. 8 By and large, experts from both sides agreed that ADOC facilities are suffering from severe systemic deficiencies that are affecting the delivery of mental-health care. For example, experts from both sides agreed that ADOC suffers' from severe overcrowding; correctional understaffing; mental-health staff shortages; deficient treatment planning; inadequate psychotherapy; inadequate use of mental-health units; inappropriate placement of segreg'a *1187 tion inmates; and inappropriate use of segregation for mentally ill prisoners.

Defendants’ correctional mental-health care expert, Dr. Raymond Patterson, is a forensic psychiatrist who has worked for various state and federal correctional institutions as a provider and as a consultant. In preparation for his testimony, he reviewed the individual plaintiffs’ medical records and deposition transcripts, visited and conducted audits of six facilities, and reviewed ADOC regulations, MHM policies and procedures, MHM monthly reports, and other expert reports. His conclusions regarding systemic deficiencies in ADOC’s mental-health care system-largely tracked those of Dr. Kathryn Burns, one of the plaintiffs’ experts: he credibly concluded that ADOC needs more mental-health staff; ADOC’s identification and classification of mental illness are inadequate; MHM’s unlicensed practitioners should be supervised; treatment planning is, deficient; too few patients are getting inpatient care; ADOC should provide hospitalization as an option for the most severely ill patients; and suicide prevention measures are inadequate. 9

Defense expert Robert Ayers is a correctional administration expert who has been involved in the California prison system for over 40 years. In preparation for giving his opinion, Ayers reviewed plaintiffs’ expert reports, visited six facilities, and talked with ADOC and MHM staff during those visits. He agreed with plaintiffs’ experts that ADOC facilities are understaffed and overcrowded. He opined that ADOC’s written policies related to mental-health care seemed to be adequate. However, he credibly explained that, mainly due to the severe understaffing and the lack of documentation, he had reasons to doubt that correctional officers and mental-health staff were actually complying with ADOC policies and procedures. He also concluded that ADOC was not providing an adequate level of care to all prisoners with mental-health needs.

Dr. Kathryn Burns, the chief psychiatrist for the Ohio Department of Rehabilitation and Correction, is a correctional mental-health expert for the plaintiffs. To prepare for her testimony, Dr. Burns visited nine major ADOC facilities, touring housing units, mental-health treatment areas, and crisis cells; she held formal interviews with 77 prisoners and spoke to an additional 25 prisoners at cell-front; she also reviewed documents such as medical records, ADOC regulations, MHM’s quality-improvement (or ‘continuous quality improvement’ or ‘CQI’) and multidisciplinary-team meeting minutes, suicide tracking sheets, and audit results. Based on her review of this evidence, she identified a wide range of problems in the delivery of mental-health care, including: insufficient mental-health staffing and correctional staffing; inadequate identification and classification of mental illness; inadequate treatment, including cursory counseling appointments, inadequate treatment plans, dearth of group counseling, and inadequate use of mental-health units; and inadequate response to self-injurious behavior and mental-health crises. Dr. Burns credibly opined that these inadequacies, separately and taken together, subject mentally ill *1188 prisoners to a substantial risk of harm from untreated symptoms, continued pain and suffering, decompensation, self-injurious behavior, and suicide.

Dr. Craig Haney, a professor of psychology at the University of California Santa Cruz, is an expert for the plaintiffs in the psychological effects on prisoners of incarceration and particularly of segregation. His testimony focused on the state of segregation units and their impact on prisoners’ mental health, based on his visits to seven facilities, interviews with numerous prisoners, and review of documents such as deposition transcripts of ADOC and MHM personnel, medical records, monthly statistical reports, and quality-assurance documents, among others. He testified that segregation units he saw were “degraded, dilapidated, deplorable,” and that these units and conditions have a significant negative psychological impact on prisoners. Haney Testimony at vol. 1, 79. Furthermore, he explained how ADOC’s segregation practices harm mental health of all prisoners, and especially that of prisoners who are already mentally ill.

Lastly, plaintiffs’ expert Eldon Vail is a correctional administration expert who has worked in corrections for over 30 years. Vail toured seven prisons, spending a day at each, and conducted confidential interviews with 42 prisoners. He also reviewed ADOC policies and procedures, meeting minutes, reports and logs generated by ADOC, deposition testimony of ADOC and MHM personnel, and other documentary evidence. His testimony focused on matters of prison administration, including security, staffing, and behavior management, and the impact of these factors on the provision of mental-health care and on prisoners’ mental health. He credibly testified that the level of correctional under-staffing at ADOC was so low as to be “shocking,” and that it has cascading effects on mental-health care: inadequate staff to transport prisoners to appointments and supervise treatment activities; inadequate staff to monitor segregation inmates, who have higher suicide risks; and overcrowded crisis cells filled with prisoners who feel unsafe due to violence in general-population dorms. Vail Testimony at vol. 1, 34.

IV. EIGHTH AMENDMENT LEGAL STANDARD

The Eighth Amendment’s prohibition on “cruel and unusual punishments” extends to a State’s failure to provide minimally adequate medical care that “may result in pain and suffering which no one suggests would serve any penological purpose.” Estelle v. Gamble, 429 U.S. 97, 103 , 97 S.Ct. 285 , 50 L.Ed.2d 251 (1976); Harris v. Thigpen, 941 F.2d 1495, 1504 (11th Cir. 1991) (“Federal and state governments ... have a constitutional obligation to provide minimally adequate medical care to those whom they are punishing by incarceration.”). The State’s obligation to provide medical care to prisoners includes psychiatric and mental-health care. Rogers v. Evans, 792 F.2d 1052, 1058 (11th Cir. 1986) (“Failure to provide basic psychiatric and mental-health care states a claim of deliberate indifference to the serious medical needs of prisoners.”). The ‘basic’ mental-health care that States must provide if needed by a prisoner includes not only medication but also psychotherapeutic treatment. See Greason v. Kemp, 891 F.2d 829, 834 (11th Cir. 1990) (“Even if this case involved failure to provide psychotherapy or psychological counselling alone, the court would still conclude that the psychiatric care was sufficiently similar to medical treatment to bring it within the embrace of Estelle.”). The State’s obligation remains even if it has contracted with private parties to provide medical care. West v. Atkins, 487 U.S. 42, 56 , 108 S.Ct. 2250 , 101 L.Ed.2d 40 (1988). That is, the State is *1189 liable for the contractor’s unconstitutional policies and practices if the contractor is allowed to determine policy either “expressly or by default.” Ancata v. Prison Health Servs., Inc., 769 F.2d 700 , 706 n.11 (11th Cir. 1985).

To prevail on an Eighth Amendment challenge, plaintiffs must prove that prison officials acted with deliberate indifference to serious medical needs. Estelle, 429 U.S. at 105-06 , 97 S.Ct. 285 . This inquiry consists of both objective and subjective tests. The objective test requires showing that the prisoner has “serious medical needs,” Estelle, 429 U.S. at 104 , 97 S.Ct. 285 , and either has already been harmed or been “incarcerated under conditions posing a substantial risk of serious harm.” Farmer v. Brennan, 511 U.S. 825, 834 , 114 S.Ct. 1970 , 128 L.Ed.2d 811 (1994). Subjectively, a prisoner must show that a prison official acted with deliberate indifference to that harm or risk of harm: that is, the official must have “known[ ] of and disregarded[ ] an excessive risk to inmate health or safety.” Id. at 837 , 114 S.Ct. 1970 ; see also Farrow v. West, 320 F.3d 1235, 1245 (11th Cir. 2003).

V. FINDINGS OF FACT AND CONCLUSIONS OF LAW

In this section, the court first discusses the basis for its finding that the plaintiffs have serious mental-health needs that require mental-health treatment. The court then lays out the common factors contributing to .the substantial risks of harm in ADOC: shortages of mental-health staff, understaffing of correctional officers, and overcrowding. After that, the court proceeds through seven different ways in which ADOC’s mental-health care system has caused actual harm and a substantial risk of serious harm; the treatment of mentally ill prisoners at Tutwiler; issues on which the court does not, at this time, find for the plaintiffs; and the defendants’ knowledge of such harm and risks, and their failure, to act in- a. reasonable manner to mitigate those risks. The section concludes with a discussion of the defendants’ legal defenses .based on Ex parte Young, 209 U.S. 123 , 28 S.Ct. 441 , 52 L.Ed. 714 (1908).

A.. ¡Serious Mental-Health Needs

To prove an Eighth Amendment claim based on inadequate mental-health care, plaintiffs must show that they have serious mental-health care needs. A serious need is “one that has been diagnosed by a physician as mandating treatment or one that is so obvious that even a lay person would easily recognize the necessity for a doctor’s attention.” Farrow v. West, 320 F.3d 1235, 1243 (11th Cir. 2003). Thus, courts may find the existence of serious needs even when prison staff have failed, to recognize an inmate’s need for treatment. Danley v. Allen, 540 F.3d 1298, 1310-11 (11th Cir. 2008) (finding that plaintiff, whose requests to see a nurse had been rebuffed, demonstrated a serious medical need in that he had difficulty breathing and swollen, burning eyes, and a fellow inmate brought his condition to the attention of correctional officers), overruled on other grounds, Randall v. Scott, 610 F.3d 701, 709 (11th Cir. 2010). A serious mental-health care need was found where a doctor, nurse, and correctional officials recognized that a prisoner “engaged in self harm” and “showed outward signs of mania and depression.” Jacoby v. Baldwin Cty., 596 Fed.Appx. 757, 763 (11th Cir. 2014).

One of the factors that courts consider in finding a serious medical need is “whether a delay in treating the need worsens it.” Danley, 540 F.3d at 1310 . “The tolerable length of delay in providing medical attention depends on the nature of the medical need and the reason for the delay.” Hill v. Dekalb Reg’l Youth Det. Ctr., 40 F.3d 1176 , 1188 (11th Cir. 1994) (citation omitted). Factors relevant to deter *1190 mining the tolerable length of delay include the “seriousness of the medical need,” “whether the delay worsened the medical condition,” and “the reason for delay.” Id. at 1189.

Because this is a Rule 23(b)(2) class action lawsuit challenging defendants’ actions “on [a] ground[ ] that applies] generally to the class” — that is, defendants’ provision of inadequate mental-health care— the plaintiffs must show that serious mental-health needs exist on a system-wide basis, rather than on an individual basis. 10 Fed. R. Civ. P. 23(b)(2). As explained in the class-certification opinion, the plaintiffs’ claim and the remedies they seek are systemic. Braggs v. Dunn, 318 F.R.D. 652, 667 (M.D. Ala. 2016). In other words, “plaintiffs are not seeking adjudication of demands for particular individualized treatment,” and any relief the court grants “would be appropriate for everyone subjected to the substantial risk of serious harm plaintiffs claim [ADOC’s inadequate mental-health care system] creates — that is, prisoners with serious mental illness.” Id. at 668 .

It is clear that a number of prisoners in ADOC’s custody have serious mental-health needs, and the issue is undisputed. As a preliminary matter, MHM places prisoners on the caseload only if they have been diagnosed with a condition that requires treatment. Therefore, all prisoners on the caseload meet the legal requirement for having a serious mental-health need. Prisoners on the mental-health caseload have wide-ranging illnesses, such as bipolar disorder, schizophrenia, schizoaffective disorder, major depressive disorder, mood disorders, borderline personality disorder, anxiety, and PTSD. 11

Furthermore, the court heard testimony from multiple prisoners, both named plaintiffs and class members, who clearly exhibited serious mental-health needs. For example, plaintiff R.M. has been diagnosed with paranoid schizophrenia and admitted *1191 that he is out of touch with reality; he testified to what were obviously his delusions regarding his blood relationships to three different well-known terrorist figures and his owing billions of dollars to the United States treasury. Similarly, medical records made clear that plaintiff Q.B. has suffered from years of delusion and hallucination; he was on involuntary psychiatric medication orders for years while in ADOC custody. Lastly, as explained earlier, plaintiff Jamie Wallace 12 had been diagnosed with bipolar disorder and schizophrenia, among other mental-health conditions, and he testified that he heard voices of his deceased mother telling him to cut himself. In sum, plaintiffs presented more than sufficient evidence establishing their serious mental-health needs.

Because only prisoners "with serious mental-health needs have a cognizable Eighth Amendment claim, when the court refers to ‘mentally ill prisoners’ in this opinion, it is referring to only those with serious mental-health needs.

B. Serious Harm and Substantial Risks of Serious Harm Posed by Inadequate Care

In addition to showing a serious medical need, plaintiffs must establish that they have been subjected to serious harm, or a substantial risk of serious harm — the second part of the ‘objective’ test under the Eighth Amendment jurisprudence — as a result of inadequate mental-health care. Put another way, plaintiffs must show that their serious medical need, “if left unattended, ‘poses a substantial risk of serious harm.’” Farrow v. West, 320 F.3d 1235 , 1243 n.13 (11th Cir. 2003)(quoting Farmer v. Brennan, 511 U.S. 825, 834 , 114 S.Ct. 1970 , 128 L.Ed.2d 811 (1994)). Defendants may be held liable for “incarcerating prisoners under conditions posing a substantial risk of serious harm.” Farmer, 511 U.S. at 834 , 114 S.Ct. 1970 . 13

The “serious harm” requirement “is concerned with both the ‘severity’ and the ‘duration’ of the prisoner’s exposure” to the harm, such that an exposure to harm “which might not ordinarily violate the Eighth Amendment may nonetheless do so if it persists over an extended period of time.” Chandler v. Crosby, 379 F.3d 1278, 1295 (11th Cir. 2004) (citation omitted). While mere discomfort is insufficient to support liability, id., “unnecessary pain or suffering” qualifies as serious harm. LaMarca v. Turner, 995 F.2d 1526, 1535 (11th Cir. 1993).

Plaintiffs may bring an Eighth Amendment challenge to a condition that is already inflicting serious harm on them at the time of the complaint or to prevent serious harm which is substantially likely to occur in the future — a substantial risk of serious harm. As the Supreme Court explained in Helling v. McKinney, 509 *1192 U.S. 25 , 113 S.Ct. 2475 , 125 L.Ed.2d 22 (1993), a case in which a prisoner challenged his prolonged exposure to secondhand smoke, “a remedy for unsafe conditions need not await a tragic event,” because “the Eighth Amendment protects against future harms to inmates,” even when the harm “might not affect all of those exposed” to the risk and even when the harm would not manifest itself immediately. Id. at 33-34 , 113 S.Ct. 2475 . In other words, plaintiffs must show “that they have been subjected to the harmful policies and practices at issue, not (necessarily) that they have already been harmed by these policies and practices.” Dunn v. Dunn, 219 F.Supp.3d 1100, 1123 (M.D. Ala. 2016)(Thompson, J.). In the class-action context, the plaintiff class must show that it, as a whole, has been subjected to policies and practices that create a substantial risk of serious harm. Braggs v. Dunn, 317 F.R.D. 634, 654 (M.D. Ala. 2016)(Thompson, J.).

Moreover, multiple policies or practices that combine to deprive a prisoner of a “single, identifiable human need,” such ás mental-health care, can support a finding of Eighth Amendment liability. Gates v. Cook, 376 F.3d 323, 333 (5th Cir. 2004) (“Conditions of confinement may establish an Eighth Amendment violation ‘in combination’ when each would not do so alone, but only when they have a mutually enforcing effect that produces the deprivation of a single, identifiable human need such as food, warmth, or exercise — for example, a low cell temperature at night combined with a failure to issue blankets.”)(citing Wilson v. Seiter, 501 U.S. 294, 304 , 111 S.Ct. 2321 , 115 L.Ed.2d 271 (1991)). The Eleventh Circuit Court of Appeals has recognized this ‘totality of conditions’ approach in prison-conditions cases. See, e.g., Hamm v. DeKalb Cty., 774 F.2d 1567, 1575-76 (11th Cir. 1985).

Mentally ill ADOC prisoners, defined here as prisoners with serious mental-health needs, have suffered harm and are subject to a substantial risk of serious harm due to ADOC’s inadequate mental-health care. Based on the trial testimony, the court finds seven interrelated areas of inadequacy: (1) identification and classification of prisoners with mental illness; (2) treatment planning; (3) psychotherapy; (4) inpatient mental-health care units; (5) crisis care and suicide prevention; (6) use of disciplinary actions for symptoms of mental illness; and (7) use of segregation for mentally ill prisoners. In all seven areas, experts from both sides by and large agreed about significant flaws affecting mentally ill prisoners. 14 MHM and ADOC staff also recognized and corroborated the existence and severity of these issues. Even Associate Commissioner Naglich essentially agreed that some of these were problems so significant that they must be fixed as soon as possible, *1193 because lives are at risk. 15 These inadequacies, alone and in combination, subject mentally ill prisoners to actual harm and a substantial risk of serious harm — including worsening of symptoms, increased isolation, continued pain and suffering, self-harm and suicide.

1. Contributing Conditions

Three conditions contribute to all of the deficiencies in ADOC’s treatment of mentally ill prisoners: understaffing of mental-health care providers, understaffing of correctional officers, and overcrowding. 16 Associate Commissioner Naglieh and defendants’ expert witnesses largely agreed with plaintiffs that these conditions present significant challenges to the system today. Correctional and mental-health un-derstaffing, both alone and in combination, impose substantial risks of serious harm to mentally ill prisoners, and overcrowding compounds these risks.

a. Overcrowding

ADOC facilities are significantly and chronically overcrowded. Publically available information on ADOC’s inmate population and capacity plainly lays out the magnitude of overcrowding: ADOC’s September 2016 monthly statistical report states that ADOC held 23,328 prisoners in facilities that are designed to hold only 13,318; this brings the' occupancy rate to over 175 %. PI. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 2, 4. 17 Plaintiffs’ expert Vail testified *1194 that the magnitude of overcrowding in ADOC is the worst he has seen in his career in corrections and consulting for other correctional systems across the country. According to Vail, California, whose overcrowded correctional system was found to be unconstitutional, approached an occupancy rate of 170 %; a three-judge court subsequently ordered the State to lower the occupancy rate to 137.5 %, a target rate that was affirmed by the Supreme Court. Brown v. Plata, 563 U.S. 493, 539-42 , 131 S.Ct. 1910 , 179 L.Ed.2d 969 (2011). The sheer magnitude of overcrowding within ADOC has meant that some ADOC facilities, including Kilby, Bibb, Staton, and Easterling, house more than double the number of prisoners they are designed to hold. PI. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 4. Even maximum-security facilities use open-bay dormitories filled with wall-to-wall rows of double bunk beds, holding up to 240 prisoners in a single room, where officers do not have a line of sight on" most of the prisoners they are assigned to supervise.

b. Mental-Health Understaffing

ADOC has maintained mental-health staffing levels that are chronically insufficient across disciplines and facilities. Witness after witness identified significant mental-health staffing shortages as one of the major reasons for ADOC’s inability to meet the rising mental-health care needs of prisoners. Most significantly, Associate Commissioner for Health Services Naglich admitted that MHM has been understaffed since 2013 and remains understaffed today. MHM’s program director Houser stated bluntly that MHM staffing shortages make it difficult to “do the work required under the contract,” and that the current caseload for MHM' staff does not meet an “acceptable standard.” Houser Testimony at vol. 2, 24-25.

Over the course of the trial, evidence showed that the mental-health caseload per MHM provider has been increasing since ,2008; largely due to three reasons: (1) an increasing number of prisoners with mental-health needs across ADOC; (2) multiple budget cuts over the years; and (3) ADOC’s long-time refusal to increase the, authorized number of mental-health staff positions despite repeated requests from MHM, even when an initiative to transfer some of the caseload to ADOC staff-so-called ‘blending of services’ — was not implemented as planned. 18

ADOC’s prisoner population has had increasing needs for mental-health services over the last decade. As múltiple MHM providers and expert witnesses from both sides testified, ADOC’s prisoner population has become more mentally ill over the last decade, both in terms of the number of individuals who need mental-health care and in terms of the acuity of mental-health care needs. MHM’s medical director, Dr. Hunter, testified that, the number of prisoners receiving regular mental-health services within ADOC (also known as being ‘on the caseload’) has been’ increasing since 2003, which has been “concerning” and “tax[ing his] ability to adequately do” what *1195 he is required to. do under the contract. Hunter Testimony at_. (For transcripts that are not yet finalized, the court leaves the page numbers blank.) He also explained that, since 2003, the number of prisoners coming into the system with severe mental illness has been increasing. MHM’s own documents showed that between 2008 and 2016, the mental-health caseload increased by 25 % across all facilities. PI. Dem. Ex. 25, Pricing, Caseload and Staffing Comparison Over Time (doc, no. 1071-5).

As the need for mental-health services has been increasing substantially, MHM and ADOC have been hiring fewer and fewer providers over the years, exacerbating the staffing shortage. In 2009, ADOC reduced MHM’s compensation under the contract and the number of authorized positions to be hired by MHM. In 2013, the state legislature further reduced ADOC’s mental-health care budget by 10 %. ADOC and MHM then re-negotiated their 2013 contract to reduce the previously agreed-upon “minimum required staffing,” cutting close to 20 full-time equivalent positions. Naglich Testimony 2-211; PI. Dem. -Ex. .140, MHM Staffing Increase Chart (doc. no. 1148-59); see also PI, Dem. Ex. 25, Pricing, Caseload, and Staffing Comparison Over Time (doc. no. 1071-5). During that same contract renewal period, ADOC and MHM also reduced the number of positions that are covered by the contractual ’staffing rebate’ provision, under which MHM must pay back ADOC if it does not fill all authorized positions. In other words, the revision allowed MHM to leave clinical staff positions unfilled without being penalized, even though the overall number of authorized positions had already been reduced. Houser described this latter modification as a way to make the reduction in payment and staffing under the contract “more palatable for MHM.” Houser Testimony at vol. 1, 49.

Another driving ■ force behind MHM’s mental-health understaffing is ADOC’s failure to implement the ‘blending of services’ initiative - successfully. Houser explained that this initiative was established in 2009 in response to ADOC’s reduction in both the amount it would pay to MHM under the contract and in the staffing provided for in the contract: MHM’s caseload would be reduced 'by transferring treatment of prisoners with lower-acuity mental-health issues to ADOC’s psychological associates; the initiative was an “attempt to make sure that the inmates received mental health services” despite the staffing reduction and increasing caseloads. Houser Testimony at vol. 1, 14. However, ADOC failed to implement the initiative across its facilities: MHM’s staffing was reduced, but at many facilities, psychological associates did not take over any caseload from MHM. Naglich explained that, because some wardens were resistant to letting psychological associates carry significant caseloads, MHM staff remained responsible for most of the patients, even though there were now fewer MHM providers than before. Houser testified that blending of services is not currently happening anywhere in ADOC in the way it was designed to happen, despite MHM’s reduced staffing levels. 'ADOC’s chief clinical psychologist Dr. David Tytell admitted that the initiative, has failed to work. However, ADOC has not restored MHM’s staffing to the pre-2009 level. 19

The result of ADOC’s refusal to increase MHM’s staffing level or even to restore staffing to the pre-2009 level has been chronic shortages of mental-health care *1196 providers. Dr. Hunter testified that the staffing shortage has had a significant impact on scheduling of psychiatric visits and medication management. Several mental-health counselors testified that their caseloads have soared; Houser testified that MHP caseloads at some facilities have been twice what they should be, which is “never an acceptable standard.” Houser Testimony at vol. 2, 25. Increasing caseloads due to understaffing have also led to a high turnover rate among staff: according to Houser, staff resign because of their frustration with increasing caseloads, leaving the rest of the staff with even higher caseloads; recruiting also suffers because of the overwhelming caseloads that mental-health staff are expected to manage. MHM’s monthly operating report submitted to ADOC for May 2016 described the problem in stark terms: “Mental health caseloads are running high at many of the facilities. Staff has attempted to accommodate the increased numbers, however quality cannot be maintained at current staffing levels.” Joint Ex. 343 (doc. no. 1038-702) at 19. As explained in more detail in the following sections, this understaffing also has prevented MHM from providing care that complies with ADOC’s administrative regulations, the contract, and professional standards for minimally adequate care in a prison system. 20

Not surprisingly, experts from both sides opined that ADOC does not have a sufficient number of mental-health staff for a system of its size. Dr. Patterson, the defense expert, concluded based on his review of medical records and site visits that ADOC’s mental-health care system is significantly understaffed. Plaintiffs’ expert Dr. Burns agreed with this assessment based on her review of medical records and MHM internal records, which revealed that caseloads for psychiatric providers and counselors were too large to allow for sufficient counselling or therapeutic group activities. Dr. Burns concluded that ADOC needs more psychiatric staff, psychologists, registered nurses, and activity technicians. 21

MHM’s corporate office — which exercises contract-compliance oversight but does not directly provide care in Alabama — has repeatedly raised mental-health under-staffing in the annual clinical contract-compliance review reports (hereafter ‘contract-compliance reports’) sent to Associate Commissioner Naglich’s Office of Health Services. Starting in 2011, each annual contract-compliance report included information on multiple facilities that were suf *1197 fering from staffing shortages, “compromising [MHM’s] ability to provide monthly follow-up for all caseload inmates.” PL Ex. 1190, 2011 Contract-Compliance Report (doc. no. 1070-8) at 15. The 2013 report also noted the impact of the staffing reduction that year, stating that “[d]espite the increase in the size of the caseload across ADOC, MHM’s contract has been compressed to include significant staffing cuts at all sites.” PI. Ex. 114, 2013 Contract-Compliance Report (doc. no; 1070^4) at 1. The report also warned that, at Donaldson, where one of the two male residential treatment units is located, “[c]urrent staffing pattern does not support the delivery of adequate services to inmates and that they have been reduced to providing minimal and ‘triage-based’ services rather than effective and thoughtfully planned treatment.” Id. at 5. In 2016, MHM reported significant backlogs in treatment and staffing shortages at Donaldson and Bullock, the two male facilities that house ADOC’s most seriously ill mental-health patients. PI. Ex. 115, 2016 Contrach-Compliance Report (doe. no. 1070-5). Even after the partial staffing increase in September 2016, Houser stated that MHM remains understaffed and pointed to mental-health un-derstaffing as a cause for a plethora of issues, including insufficient identification of mental illness at intake and referrals; missed counseling appointments and group sessions; and inadequate monitoring of prisoners in mental-health crises.

Based on Associate Commissioner Nag-lich’s testimony and other evidence, the court finds that MHM has been consistently and significantly understaffed at least since 2013, and that it is still understaffed even after ADOC approved a small staffing increase in September 2016 as part of its one-year contract extension.

c. Correctional Understaffing

In addition to mental-health understaff-ing and overcrowding, a significant shortage of correctional officers also hinders the delivery of mental-health care and poses a substantial risk of harm to prisoners who need mental-health care. As with mental-health staffing shortages, witness after witness, including both defendants, testified that a significant shortage of correctional officers has been one of the biggest obstacles to providing mental-health care in ADOC. In Associate' Commissioner Naglich’s words, the problem of insufficient mental-health staffing is “compounded by” the lack of sufficient correctional staffing at ADOC. Naglich Testimony at vol. 2, 208.

ADOC has reported an ever-increasing shortage of correctional officers in its annual reports arid monthly operating reports since 2006. In 2010, ADOC summarized that “[c]orreetional staffing continues to fall- short of required levels — impacting the inmate to officer ratio and overtime necessary to cover essential posts,” and reported that the shortage rate was 12.2 % at close-custody (highest security) facilities and 21.2 % at medium-security facilities. Joint Ex. 463, Vail Expert Report (doc. no. 1038-1048) at 39 (quoting ADOC Annual Report FY 2010). Essentially the same statement regarding the officer shortage appeared in every annual report until 2013, when the shortage rate across facilities shot up to 43.3 %. The report in 2015 showed officer shortage rates of over 25 % at 13 of the 15 major prisons and over 50 % at six of those; the highest was 68 % at Bibb. Donaldson was barely undpr 25 %; only one prison, Hamilton, the facility for the elderly and the' infirmed, was below 25 %. Id. at 39-40 (citing ADOC Annual Report FY 2013, 2015). As of September 2016, ADOC reported having filled only about half of the authorized positions for correctional officers. PI. Ex. 1260, September 2016 Monthly Statistical Report (doc. no. 1097-19) at 16 (showing 51.1 % overall *1198 staffing level). 22 The staffing level continued to drop throughout 2016, according to Associate Commissioner of Operations Grantt Culliver.

Understaffing has been a persistent, systemic problem that leaves many ADOC facilities incredibly dangerous and out of control. Defendants’ correctional administration expert Robert Ayers observed multiple high-security units not being monitored at all and an entire unit at Bibb overseen by a single control booth officer and a single officer on the floor; he opined that such understaffing was “not acceptable.” Ayers Testimony -at_Plaintiffs’ correctional administration expert Vail agreed with this conclusion and elaborated that many facilities are struggling to have sufficient numbers of correctional officers to station at. least one officer per dorm— including the highest-security facilities, such as Holman and Kilby.. Not surprisingly, a severe .shortage of officers leads to dangerous and violent conditions, especially in high-security facilities, with overcrowded dormitories. 23 In these conditions, prisoners and correctional officers alike are justifiably afraid for their safety — a jarring image that many prisoner-witnesses and experts, painted in their testimony. For example, class member M.P., w;ho is now housed in Ventress, stated repeatedly how dangerous it was to be in a general-population dorm at St. Clair; he was enormously relieved to be transferred to another prison. 24 Multiple experts also *1199 testified that during their site visits, prison officials did not allow them to enter certain parts of the prison, such as the second and third tiers of the Holman segregation unit and a whole half of Bibb, because the officials could not guarantee their safety. 25

As a result of the officer shortage, ADOC has an exceedingly high overtime rate. Overtime rate refers to the, proportion of the number of hours worked by correctional officers as overtime compared to the total number of hours worked. A high overtime rate undermines security and officer morale, which in turn has negative implications for mental-health care. ADOC’s chief of staff Steve Brown admitted that the current overtime rate of over 20 % is not sustainable in the long run, because it decreases retention of officers and increases the number of disciplinary actions against officers. Multiple vulnerability analyses — ADOC’s internal critical assessments of each facility’s security risks — also found that mandatory overtime and overuse of overtime have affected staff morale and contributed to high turnover rates. PI. Ex. 146, Bullock Vulnerability Analysis (doc. no. 1087-3); PI. Ex. 185, Donaldson Vulnerability Analysis (doc. no. 1087-6); PI. Ex. 204 Elmore Vulnerability Analysis (doc. no. 1087-8). 26

This chronic and severe correctional un-derstaffing has compromised mental-health care in many ways. Most significantly, as discussed in more detail in Part V.B.4, correctional officers are needed to provide security for mental-health programming and escort prisoners from their cells to appointments if they are not in general population. Due to insufficient correctional staffing, appointments and group activities are frequently canceled- and delayed, significantly impairing MHM staffs ability to provide treatment. See, e.g., PI. Ex. 115,2016-Contract-Compliance Report (doc. no. 1070-5) at 3 ,(MHM staff not being able to access patients:at Bullock, Donaldson, Holman, St. Clair,, and Staton due to correctional staffing shortages, and expressing concern about their own safety at five facilities); PI. Ex. 105, 2014 MHM Implementation Review Report (doc. no. 1070-3)- at 3 (20 to 70 % of mental-health appointments were canceled due to correctional officer shortages at the Donaldson residential treatment unit in 2014). Based *1200 on the testimony of Ayers, one of the defense experts, and almost all MHM providers and managers who testified, the court is convinced that the correctional staffing level falls intolerably short of providing adequate care to prisoners who need to be escorted to their mental-health appointments.

Second, understaffing impacts correctional officers’ ability to supervise mentally ill prisoners effectively. According to plaintiffs’ expert Vail, understaffing compromises overworked correctional officers’ alertness and ability to respond to incidents, crises, and emergencies, and to exercise the patience and restraint necessary to supervise mentally ill prisoners. This effect is even more pronounced in segregation and crisis cells. Without sufficient correctional staff, officers are unable to check on prisoners isolated from the rest of the population as frequently as they must in order to guarantee their safety. As a result, decompensating prisoners go unnoticed, leading to extended suffering without access to treatment, and more frequent crisis situations.

Correctional understaffing, combined with overcrowding, also has a more direct impact on prisoners’ mental health. The combination of overcrowding and under-staffing leads to an increased level of violence, both because of the difficulty of diffusing tension and violence in an overcrowded open-dormitory setting, and because of the lack of supervision by correctional officers. See PI. Ex. 1260, ADOC September 2016 Monthly Statistical Report (doc. no. 1108-37) at 12 (reporting nearly 200 assaults with serious injuries and seven homicides in the fiscal year ending in September 2016). According to Dr. Haney, plaintiffs’ expert on correctional mental health and solitary confinement, prisoners’ legitimate fear of violence is a common source of anxiety and mental instability: for prisoners who already suffer from mental illnesses, this environment increases their likelihood of decompensation. The level of danger and lack of control arising from overcrowding and insufficient staffing also contributes to a punitive culture, in which officers prioritize security concerns over mental-health treatment and are quick to treat mental-health symptoms as behavioral problems; dealing with violence and emergencies also diverts correctional resources away from regular mental-health programming and treatment. Untreated or undertreated mental illness in turn creates a greater need for mental-health services, provision of which is limited by the very shortage of officers that created the increased need in the first instance. Furthermore, mental-health problems are much more likely to go unnoticed in overcrowded and understaffed prisons, because correctional officers who are spread too thin are less likely to notice any unusual behavior by a particular prisoner. These observations made by Dr. Haney all rang true in the evidence before the court. Lastly, as Dr. John Wilson, a psychologist who serves as one of the directors of MHM’s national Clinical Operations Department, explained to MHM’s program director Houser, “experience and research” confirm that suicides tend to increase with overcrowding, and “basic unrest at a systems level” can cause a spike in suicides. PI. Ex. 1224, October 1, 2015 Email from Wilson to Houser (doc. no. 1117-24) at 2. In fact, the suicide rate within ADOC has more than doubled in the last two years, as ‘unrest at a systems level’ continues to plague ADOC facilities. Taken together, ADOC’s low correctional-staffing level, in the context of its severely overcrowded prisons, creates a substantial risk of serious harm to mentally ill prisoners, including continued pain and suffering, decompensation, self-injury, and suicide.

*1201 2. Identification and Classification of Prisoners’ Mental-Health Needs

As one expert put it, ADOC’s mental-health care system “falls apart at the door”: the system fails to identify and classify appropriately those with mental illnesses, and the effect of this under-identification cascades through the system. Haney Testimony at vol. 1, 30. Because of inadequate identification and classification, seriously mentally ill prisoners languish and decompensate in ADOC without treatment, ending up in crisis care and engaging in destructive — sometimes fatal — self-harm.

Timely identification and appropriate classification of prisoners with mental illness are essential to a functioning mental-health care system. As experts explained, and as common sense would dictate, mental-health treatment cannot begin unless providers are aware of who needs treatment and for what. Failure to identify those who need mental-health services denies them access to necessary treatment, creating a substantial risk of harm to those who remain unidentified. See LaMarca v. Turner, 995 F.2d 1526, 1544 (11th Cir. 1993) (affirming conclusion that systematic denial of access to treatment constitutes deliberate indifference to a serious medical need).

a. Inadequate Intake Process

ADOC’s system for identifying prisoners with mental illness is significantly inadequate. According to three experts — defense expert Patterson and plaintiffs’ experts Burns and Haney — the percentage of prisoners within ADOC with mental illness (referred to as the ‘prevalence rate’) is substantially lower than the national average: the average rate of mental illness for men in correctional systems ranges between 20 % and 30 %; ADOC’s prevalence rate is between 14 % and 15 %. See Joint Ex. 346, June 2016 MHM Monthly Statistical Report (doc. no. 1038-708) at 1.

As experts from both sides testified, ADOC’s prevalence rate is abnormally low and reflects that the system is under-identifying prisoners with mental illness. Defense expert Dr. Patterson explained that experts do not expect to see much variation in actual prevalence rates across correctional systems, and that he has not seen anything that suggests that ADOC would have a lower prevalence rate than other correctional systems for any reason other than under-identification. Dr. Bums agreed and explained that it is highly likely that the abnormally low prevalence rate is due to under-identification, rather than because Alabama prisoners have fewer mental-health issues compared to those in other States. She added that she does not know of any States that have lower prevalence rates than Alabama. Assuming that ADOC’s actual prevalence rate for mental illness actually tracks the national figure of between 20 % and 30 %, somewhere between 1,200 and 3,600 prisoners should be receiving mental-health care but are not, because between 5 % and 15 % of ADOC’s 24,000 prisoners have not been identified as having a mental illness.

A closer examination of the two main processes of identifying prisoners with mental-health care needs — intake and referral — sheds light on why ADOC’s prevalence rate is so low. First, ADOC’s mental-health screening process at intake fails to identify a substantial number of prisoners with mental-health issues. Licensed practical nurses, who have very limited training, are responsible for conducting mental-health screening for prisoners at intake at Kilby (for all male prisoners) and Tutwiler (for all female prisoners). No higher-level provider supervises the LPNs during the intake process. The intake LPN fills out forms and questionnaires and decides *1202 whether to refer a prisoner for further examination by a psychiatrist or a nurse practitioner. If the LPN determines that a prisoner does not need to be referred tq a psychiatrist or nurse practitioner, a mental-health code of MH-0, denoting no need for mental-health care, is entered into the system. Prisoners who are designated as MH-0 by an LPN do not receive any further evaluation or any mental-heálth treatment unless reférred to mental-health services later by a staff member or the prisoners themselves. On the other hand, if the LPN refers the prisoner for evaluation, a psychiatric provider completes' an evaluation, gives a diagnosis if appropriate, and assigns a mental-health code, which determines the level of care the prisoner subsequently receives and ranges from MH-0 (no mental-health need) to MH-6 (in need of hospitalization). 27

Experts from both sides agreed, and the court finds, that the intake screening process conducted by an LPN without any on-site supervision by a higher-level provider contributes to under-identification of prisoners with mental illness. This is because LPNs, who only have 12 to 15 months of general medical training — very little of which may be related to mental health— are not qualified to assess the presence or acuity of mental illness symptoms based on information obtained during the intake process. Intake forms that LPNs fill out include questions, that require clinical assessments, rather than simple yes-or-no questions based on physical observations. See Joint Ex. 85, Admin. Reg. § 601 Mental Health Forms and Disposition (doc. no. 1038-106);, Burns'Testimony at vól. 1, 44-45. According to the experts, LPNs are not qualified to make such clinical assessments. Moreover, although LPNs may make referrals- -based on self-reported symptoms of mental illness, a proper intake system cannot solely rely on self-reporting to identify mental-health needs. As Dr. Burns testified, the use of unsupervised LPNs for. intake mental-health screening presents an “obvious” risk of under-identification. Burns Testimony at vol.l, 61-62. 28 .

*1203 The use of inadequately supervised LPNs for intake is compounded by insufficient mental-health staffing. Houser testified that MHM does not have sufficient staffing or space to conduct mental-health screenings at Kilby (where all male prisoners are screened), and her staff have had to send prisoners to other facilities without conducting the initial intake screening. This in turn has increased the workload for mental-health staff at the receiving facilities and has created delays in the provision of mental-health care to those who need treatment. Dr. Patterson, the defense expert, agreed that insufficient staff at intake has led to insufficient identification of prisoners with mental illness, and that this failure to identify increases the risk of continued pain and suffering and potential suicides among those who are not receiving the mental-health care they need.

b. Inadequate Referral Process

The other mechanism for identifying and classifying prisoners with mental illness, the referral process, is riddled with delays and inadequacies. The purpose of the referral process is to identify prisoners whose mental illnesses develop during their incarceration and prisoners whose mental-health needs were not identified during the intake process. Furthermore, the referral process enables the system to respond to the changing mental-health needs of prisoners as they arise, regardless of their initial mental-health assessment results. In a functioning system, referrals from prisoners or staff would be triaged based on the urgency of the articulated needs: some may warrant immediate action, such as placement in a suicide-watch cell or an immediate evaluation by a psychiatrist, while others may be addressed over a longer period of time. According to Dr. Patterson, the defense expert, triaging is important because the assessment process enables clinicians to determine appropriate next steps, and delays in doing so pose a risk of untreated symptoms, including a risk of death from critical yet unmet treatment needs.

As with the intake screening procedure, experts from both sides concluded that ADOC’s referral process suffers from serious deficiencies. First, ADOC does not have a system to triage and identify the urgency of each request, and to make referrals according to the level of urgency. MHM’s contract-compliance reports have identified this issue year after year, starting in 2011: the reports stated that processed referral slips did not reflect acuity levels, and the logs of referrals did not record the relevant date and time information, making it impossible to ensure timely processing and referrals. Despite perennial indications that referral requests were being processed in a haphazard manner, ADOC still does not have any system of tracking and processing referrals to ensure that urgent requests are actually referred to providers, or that providers are able to handle requests in a timely fashion: an audit performed- by defense experts in May 2016 revealed that referral forms still do not note urgency levels that would enable triaging. 29

Second, the referral process is inadequate because correctional officers are ill-positioned to notice behavioral changes. As ■plaintiffs’ expert Vail testified, severe overcrowding and understaffing make it diffi *1204 cult for correctional officers to notice behavioral changes. It is simply unrealistic to rely on ADOC’s overburdened correctional officers to identify and refer prisoners who may need mental-health treatment, except perhaps for those prisoners with the most obvious symptoms of mental illness.

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. Experts described examples of “increasingly desperate acts” to get the attention of MHM and necessary services, such as self-injury, fire setting, and suicide attempts. Joint Ex. 460, Burns Expert Report (doc. no. 1038-1044) at 29; Haney Testimony at vol. 1, 72 (describing frequent fires in segregation units as desperate attempts to get attention for their needs, including mental-health needs). The court also heard from class member J.A., who has repeatedly engaged in self-harm and expressed suicidal ideation. After summarizing his various attempts to obtain mental-health services while in segregation, including starting fires, J.A. observed, “[Gjetting help in prison is harder than getting out of prison.” J.A. Testimony at _These are snapshots of unnecessary pain and suffering that could be avoided or at least minimized if prisoner requests for mental-health services were being addressed on a timely basis.

c. Inadequate Classification of Mental-Health Needs

ADOC also fails to classify the severity of mental illnesses accurately. The mental-health coding system is intended to reflect the level of functioning a mental-health patient has and correspond to his or her treatment needs and housing requirements. Through multiple revisions, the coding system now includes 13 different codes, ranging from MH-0 tó MH-9, with sub-codes for some levels, such as MH-2d. In broad strokes, a higher numbered MH code reflects more intensive care needs: MH-0 refers to no mental-health care need; MH-1 and MH-2 refer to mild impairment or stable enough to receive only outpatient care; MH-3 through MH-5 refer to those who need inpatient care, in either the residential treatment unit (RTU) or intensive stabilization unit (SU); MH-6 refers to those who need to be hospitalized. See Joint Ex. 105, Admin. Reg. § 613 (doc. no. 1038-127). 30

Testimony from multiple witnesses and experts made clear that ADOC’s mental-health coding system often fails to accurately reflect prisoners’ mental-health needs. 31 For example, plaintiff R.M. has been coded MH-2 and housed in general population for most of his incarceration since 1994, despite his severe paranoid schizophrenia and resulting delusions. He was eventually given a higher code and transferred to the Bullock RTU, but Dr. *1205 Burns testified that he may need an even higher level of care, and that he suffered from inadequate care while housed for years in an outpatient facility. Likewise, a prisoner identified as # 12 in Dr. Burns’s report was clearly delusional and believed that televisions and radios were speaking to him; he was in an outpatient facility at the time of his interview with Dr. Burns, but needed to be in a long-term, inpatient facility due to the severity of his schizophrenic symptoms. An email from Associate Commissioner Naglieh to Dr. Hunter in December 2015 discussed a schizophrenic prisoner who was clearly delusional and eventually killed another prisoner and threatened to kill a correctional officer; he had been coded as MH-1, which is intended to denote someone who is stabilized with a ‘mild’ impairment. Lastly, Dr. Haney gave examples of patients who have been repeatedly placed on suicide watch for engaging in self-harm and suicide attempts but were designated as MH-0— that is, not having any mental-health treatment needs — including plaintiffs L.P and R.M.W., and former plaintiff J.D. Haney Testimony at vol. 2, 113-20; see PI. Dem. Ex. 131, Movement History of Exemplar Plaintiffs (doc. no. 1126-10).

d. Inadequate Utilization of Mental-Health Units

As experts from both sides concluded, ADOC does not adequately utilize residential treatment unit beds and fails to provide residential-level care to those who need it, leading to persistent or worsening symptoms. Defendants’ expert Dr. Patterson opined that roughly 15 % of prisoners on the mental-health caseload should be housed in RTU or intensive stabilization unit settings; in -other words, approximately 515 ADOC prisoners should be housed in the RTU or the SU. 32 However, only 310 of the 376 RTU and SU beds were being used to house prisoners with mental-health needs as of S¿ptember 2016. Joint Ex. 344, September 2016 Monthly Operating Report (doc. no. 1038-703). This practice of not filling even existing mental-health unit beds has persisted for years, as reflected in MHM’s monthly operating reports. See, e.g.. Joint Ex. 321, December 2015 Monthly Operating Report (doc. no. 1038-666) at ADOC0319118-19; Joint Ex. 320, December 2014 Monthly Operating Report (doc. ho. 1038-665) at ADOC0319016-17 (showing 299 beds occupied in December 2015 and 177 beds occupied in December 2014). 33 Dr. Patterson credibly opined that this significant shortfall suggests ADOC has been under-identifying those who need residential treatment — a problem that starts with the inadequate intake screening, process. He also observed another flaw in RTU admission management: he explained that those who are repeatedly sent to the SU should be admitted, to the RTU to receive more long-term, intensive treatment, rather than being released back to general population after a stay, in the SU. He also npted that prisoners who are admitted to RTUs often stay only for a short period, despite their pronounced needs for long-term treatment. Because there is little programming available in the RTU, the utility of an RTU placement is quickly exhausted, according to Patterson.

*1206 Dr. Burns agreed with Dr.. Patterson’s assessment that ADOC needs to house more patients in the RTU, especially when RTUs have available beds. She also observed during her facility visits multiple prisoners who needed residential treatment but were in general population.

In sum, ADOC’s significantly inadequate identification and classification practices create a substantial risk of serious harm to prisoners with mental illness. These practices result in a failure to treat or under-treatment of prisoners’ serious mental-health needs. As will be discussed later, these practices also have a downward-spiral effect on the rest of the system: those who do not get needed treatment often end up in crisis cells, frequently receive disciplinary sanctions, and. may be placed in segregation, where they have . even less access to treatment and monitoring.

3. Inadequate Treatment Planning

Correctional systems have a duty to provide minimally adequate mental-health care to prisoners with serious mental-health needs. Estelle v. Gamble, 429 U.S. 97, 104 , 97 S.Ct. 285 , 50 L.Ed.2d 251 (1976) (deliberate indifference to serious medical needs of prisoners constitutes “unnecessary and wanton infliction of pain proscribed by the Eighth Amendment”) (internal quotation and citation omitted); Greason v. Kemp, 891 F.2d 829, 834 (11th Cir. 1990) (holding that prisoners have a constitutional right to psychiatric care under Estelle v. Gamble). Expert testimony from both sides established that such minimally adequate care requires treatment planning. Treatment planning is the foundation of all forms of health care; through the process, providers involved in the treatment identify the patient’s target symptoms, treatment goals, and - next steps, and coordinate long-term care as necessary. When staff from multiple disciplines — for example, psychiatric, psychological, nursing, and even correctional— are involved in a patient’s treatment, treatment planning should involve key people from each discipline in order to ensure consistent and informed treatment. Treatment planning is particularly important in the prison context, where prisoners have almost no ability to ensure the consistency of them own treatment; it is even more crucial in the context of, ADOC, where prisoners are frequently transferred across correctional facilities and the staff turnover rate is high. As experts described, without coordinated long-term planning, treatment is often ineffective and runs a substantial risk of prolonging pain and suffering of those who have treatable mental illnesses. Failure to provide meaningful .treatment planning constitutes a substantial deviation from acceptable standards of prison health care; such deviations can pose a substantial risk of serious harm to those who have serious psychiatric needs. Steele v. Shah, 87 F.3d 1266, 1269 (11th Cir. 1996) (noting that providing care where the quality is “so substantial a deviation from accepted standards” can constitute an Eighth Amendment violation). 34

*1207 ADOC fails to provide adequate treatment planning. First, experts for both sides found that ADOC’s treatment plans are not individualized to each prisoner’s symptoms and needs, résulting in ‘cookie-cutter’ plans that remain the same even though there may have been changes in that prisoner’s mental-health state. As defense expert Dr. Patterson explained, a patient’s lack of progress in treatment ■does not justify the use of a cookie-cutter treatment plan: providers should try different interventions that could be effective, rather than sticking to the same intervention when the patient is not responding to it. Likewise, treatment plans should reflect the changes in the treatment environment, such as an admission to the SU or placement on suicide watch. However, ADOC treatment plans often have general patient goal statements such as “identify triggers” or “identify coping mechanism” repeated in subsequent plans, without showing any progress or change in the mental state of the patient; they also often fail to reflect the fact that the patient has been placed in a different environment' that would impact his or her mental health and treatment mode. Whether the rote repetition results from a lack of follow-through on the plans or mere sloppiness in filling' out the plans, both present hazards to prisoners with mental illness.

ADOC’s treatment-team meetings are also inadequate. Treatment-team meetings are an essential part of the treatment planning process, where providers from various disciplines involved in the patient’s treatment discuss developments and next steps to ensure coordinated care. However, the meetings at ADOC happen haphazardly, with members of the treatment team missing from the meetings and signing new treatment plans on different days. This haphazard attendance creates a risk of different providers having an inconsistent approach or course of treatment for the same patient because some of the treatment .team are unaware that a new treatment plan has been put into effect. Furthermore, the meetings frequently occur without any participant, with prescription privileges, especially at some outpatient facilities where the only provider with prescription privileges is a nurse practitioner who visits the facility as infrequently as pnce per month. As a result, treatment plans are often developed without the input of a provider with expertise in psychotropic medication. Experts from both sides agreed that ADOC’s treatment planning without all necessary participants is problematic and falls below the standard of care because it deprives patients of a coherent treatment plan and- continuity of care.

Inadequate treatment planning subjects mentally ill prisoners to the risk of exacerbating symptoms, prolonged pain and suffering, serious injury from self-harm, and even death. As Dr. Burns explained, treatment plans serve an essential function of making sure that all’providers’ treatment is consistent. Dr. Burns credibly opined that not having a consistent approach to a prisoner’s treatment poses a. risk of exacerbating or neglecting problems that may arise from mental illness, such ás self-injury. Specifically, according to Dr. Burns, failing to address the issue of repeated self-injury due to a lack of coordinated treatment and inconsistent approaches by different providers creates a substantial risk that patients will continue to -engage in self-harm; these patients can eventually end up disabled or dead as a result of continued self-harm. Defense expert Patterson agreed with Burns’s emphasis on the critical importance of coordinated'treatment and identified inadequate treatment planning as one of the most *1208 significant deficiencies in ADOC’s mental-health care system.

In the context of ADOC, where transfers of prisoners and changes in providers are frequent, the impact of inadequate treatment planning is exacerbated. Because written treatment plans are generic, counselors and patients often have to start from scratch when patients are moved from counselor to counselor. A former mental-health professional testified that prisoners who are transferred to a new counselor are often adversely affected, not only because the counselor has to start anew the process of building rapport with the prisoner, but also because treatment plans and progress notes often contain insufficient information to enable a different provider to learn about the patient or continue a consistent course of treatment. Plaintiff C.J. also testified to the difficulties in having to start over with a new counselor after each transfer. In sum, without the continuity of care and consistent treatment approaches provided through proper treatment planning, providers are substantially hindered from addressing symptoms of mental illness, exposing patients to continued pain and suffering, worsening self-injurious behavior, serious bodily injury, or even death.

4. Inadequate Psychotherapy

Constitutionally adequate mental-health care in prisons requires more than simply providing psychotropic medications to mentally ill prisoners. Prison systems must provide not only psychotropic medication but also psychotherapy or counseling to prisoners who need it to treat their serious mental-health needs. See Greason v. Kemp, 891 F.2d 829, 834 (11th Cir. 1990) (adopting district court’s conclusion that “[e]ven if this case involved failure to provide psychotherapy or psychological coun-selling alone, the court would still conclude that the psychiatric care was sufficiently similar to medical treatment to bring it within the embrace of Estelle”). As Dr. Burns explained, from a clinical perspective, having both modalities of treatment— medication and counseling — is important because one particular modality does not work for everyone. According to Dr. Burns, research indicates that seriously mentally ill patients need counseling and medication, along with non-structured or recreational activities, and that psychotherapy is an effective and essential mode of treatment for mental illness. She credibly opined, and the court finds, that not providing individual or group therapy poses a substantial risk of serious harm, including continued symptoms, pain, and suffering, as well as self-harm and suicide attempts.

Insufficient mental-health and correctional staffing at ADOC undermines the availability and quality of individual and group counseling sessions. First, as explained earlier, inadequate mental-health staffing combined with the increasing number of prisoners on the mental-health caseload has driven up the number of prisoners on each counselor’s caseload. As a result, both the frequency and quality of counseling sessions have suffered over time, according to both experts and MHM providers. MHM’s medical director Dr. Hunter testified that the caseload has increased in recent years to the point of taxing his staffs ability to carry out MHM’s contractual obligation: MHM counselors’ caseloads have increased from 60 patients to between 80 and 90; some facilities have only one counselor, who treats more than 100 patients; nurse practitioners’ caseloads have increased from 10-15 patients per day to 20-25 patients per day.

MHM’s program director Houser also testified that caseloads for counselors were sometimes twice as much as they should be; as a result, she said, counselors are “continually getting behind.” Houser Testi *1209 mony at vol. 2, 25. In addition to seeing patients, counselors also have to attend meetings, document their treatment actions, design treatment plans, go on rounds in segregation units, and respond to crises as they arise. 35 Due to counselors’ increasing caseloads and mounting job responsibilities, individual counseling appointments are frequently canceled or delayed. For example, during a spot audit of the caseload at Bibb, 212 out of 213 cases had overdue counseling appointments. PI. Ex. 576, December 2, 2015 Email from Davis-Walker to Houser (doc. no. 1112— 26). Defense expert Patterson also observed that counseling appointments are frequently delayed due to staffing shortages and opined that “these delays contribute to a failure to provide necessary mental health services”; the potential harm in such delayed appointments includes “continued pain and suffering of mental health symptoms including suicide and disciplinary actions due to inadequate treatment.” See Joint Ex. 461, Patterson Expert Report (doc. no. 1038-1046) at 64.

Caseloads that are — as MHM’s Houser put it — much higher than an “acceptable standard” may explain why so many prisoners testified that ‘counseling sessions’ do not amount to much. Dr. Patterson’s review of the medical records within ADOC revealed that most progress notes from counseling sessions only contained short descriptions of symptoms, instead of reflecting clinical judgments and overall assessments of the patient’s progress. Similarly, Dr. Burns noted that the overwhelming majority of progress notes she reviewed indicated that the patient was ‘fine,’ had ‘no complaints,’ or had nothing to talk about. She explained that a short, vague statement like “I’m alright” is not a sufficient indicator of a stable mental-health state: instead of moving on to the next patient simply because the patient’s initial self-reporting does not expressly indicate distress, the clinician should probe deeper; notes on asking follow-up questions about medications, mood, job assignments, or disciplinary sanctions would reflect a proper counseling session. Based on the prisoners’ descriptions and the experts’ observations, the court finds that counseling sessions are often inadequate.

The chronic lack of sufficient correctional staffing has also contributed to frequent disruptions in the provision of psychotherapy. Dr. Burns credibly opined that insufficient correctional staff has interfered with access to treatment, as evinced by frequently canceled or delayed individual counseling sessions and group sessions. In particular, as she noted, the frequency of counseling sessions for those in segregation is especially low due to officer shortages: since segregation inmates must be escorted from their cells by correctional officers, mental-health appointments are frequently canceled or delayed when there are not enough officers to cover both the essential security posts and mental-health *1210 appointments. Ayers, defendants’ correctional expert, also credibly opined that ADOC was failing to respond to the needs of mentally ill prisoners due to the correctional staffing shortage. Likewise, a nurse practitioner at Donaldson credibly testified that she has experienced a persistent problem of not being able to see patients due to a lack of correctional staffing, and that the problem has been getting worse over the years. She and other providers testified that when insufficient correctional staffing does not allow prisoners to be escorted to the mental-health offices, the mental-health providers may go' to the cells themselves and attempt to talk-tó their patients at the cell-front. However, as agreed by MHM’s medical director Hunter and experts Burns and Haney, these cell-front check-ins are insufficient as counseling -and do not constitute actual mental-health treatment; Haney explained that these contacts serve solely a monitoring purpose — that is, to ensure that the patient is responsive and not decompensat-ing, rather than to treat the underlying mental illness. Indeed, while visiting five different facilities and their segregation units, the court observed the difficulty of standing outside a closed cell door to speak to a prisoner about mental-health needs: most cell doors are solid with small, perhaps 12-by-6-inch windows, some of which were completely fogged over- and others shielded by wire mesh or obfuscated by paper pasted on the window, either by the prisoner or from outside; and most of these segregation or high-security cells áre in' large, auditorium-like spaces, where sounds echo throughout the units, resulting in a panoply of unintelligible yet very loud noises. Conducting a counseling session across the door in these loud spaces seemed nearly impossible: the court had a hard time imagining having a meaningful conversation'in such an environment, let alone a conversation for the purposes of mental-health treatment.

As with these 1 cell-front sessions, ADOC’s provision of psychotherapy often lacks confidentiality. Experts and other clinician witnesses explained that confidentiality between providers and patients is a hallmark of and a necessary condition for mental-health treatment, yet some ADOC facilities lack a confidential setting for counseling sessions. Obviously, cell-front interactions between mental-health staff and prisoners are not confidential, as many staff witnesses testified, and as the court observed 'firsthand. Moreover, many facilities lack mental-health offices with windows and doors that would ensure the visibility of the counseling session to the correctional officer who is providing security without sacrificing sound confidentiality. For example, as the court saw on its tour of St. Clair Correctional Facility, 'the walls in the mental-health offices do not extend from floor to ceiling, and they lack doors; in other words, the offices resemble tall cubicles. Anyone nearby, including other prisoners and the correctional officer who escorted the -prisoner there, could hear the content of a counseling session. Moreover, correctional officers often stand by the door of counseling offices' with the door ajar for safety purposes, and counseling sessions are sometimes held in lieutenant’s offices where other correctional officers are present arid holding disciplinary hearings. As Dr. Haney explained, prisoners often do not feel safe sharing their mental-health issues in the presence of correctional officers or other prisoners because what they share with the mental-health staff may make it easier for others to exploit 'them; as a result, the lack of confidentiality undermines the effectiveness and quality of counseling sessions. 36

*1211 The quality of psychotherapy also suffers due to use of unsupervised, unlicensed counselors, referred to as ‘mental health professionals’ in ADOC. The court finds, based on expert testimony from both sides, that the lack of supervision for unlicensed MHPs is a significant, system-wide problem affecting the delivery of mental-health care within ADOC. ADOC’s own contract for mental-health care specifies that all MHPs must be licensed. However, only four out of 47 MHPs employed at. ADOC were licensed as of February 2016, and this problem has persisted for years. 37 The standard of care and state regulations mandate that an unlicensed counselor be supervised by a licensed psychologist, who is required to co-sign the counselor’s notes and review the treatment provided. Because MHM employs only three psychologists, most MHPs work at prisons without a psychologist, and the chief psychologist of MHM, Dr. Woodley, provides.no actual supervision to unlicensed MHPs. In fact, most MHPs’ clinical work is supervised by their respective site administrators, who are also mostly unlicensed counselors with their own caseloads — in other words, the supervisors generally have the same level of credentialing and education as the MHPs they are supervising. If the site administrators have any problems, they consult with Dr. Woodley. Dr. Patterson, a defense expert, credibly opined that it is unacceptable for an unlicensed counselor, rather than a licensed psychologist, to supervise another unlicensed counselor. He identified the lack of supervision of unlicensed providers as a systemic deficiency.

ADOC’s provision of group therapy is also inadequate. Dr. Burns testified that infrequent and. inadequate individual counseling can pose a substantial risk of serious harm to prisoners with mental illness, if the same patients do not have access to group therapy. Burns further explained that group therapy is especially important in a correctional system, which often does not have enough resources to provide individual counseling to all of the prisoners who need psychotherapy. Group sessions, like individual therapy, help prisoners with mental illness manage their symptoms, so that they do not deteriorate to the point of needing residential treatment; outpatient group therapy also enables mental-health staff to identify those who need more intensive treatment. Burns opined that therapy groups on depression, post-traumatic stress disorder, and medication management issues should always be offered to those on’ the' mental-health caseload, and that not offering such group treatment in the context of an under-resourced correctional mental-health system creates a substantial risk of harm to prisoners suffering from those illnesses. Despite the importance of group therapy for those who receive inadequate individual therapy, many seriously mentally ill ADOC prisoners with little access to individual therapy also have little access to group therapy. MHM’s program director Houser admitted that groups have been not happening at many facilities, including RTUs and SUs, due to the correctional staffing shortage.-

*1212 In sum, mental-health understaffing, correctional understaffing, the use of unsupervised, unlicensed counselors, and lack of confidentiality all undermine the efficacy and frequency of psychotherapy for mentally ill prisoners within ADOC. These conditions have created a substantial risk of serious harm for those who need counseling services, leaving them at a greater risk for continued pain and suffering, self-injurious behavior, suicidal ideation, and, as discussed later, disciplinary actions in response to symptoms of mental illness.

5. Inadequate Inpatient Care

Problems of inadequate psychotherapy and treatment planning become even more pronounced for prisoners in mental-health units, where ADOC houses the most severely mentally ill prisoners in its custody. Mental-health units (also referred to as inpatient units) include residential treatment units and intensive stabilization units. These units, which are located at Donaldson, Bullock, and Tut-wiler, house about 2 % of prisoners within ADOC’s custody. 38 Given that prisoners housed in mental-health units have already been identified as having the most severe mental-health needs within ADOC, these patients are at higher risk of de-compensation than other mentally ill prisoners if treatment is insufficient or if their housing environment is not therapeutic. And yet, despite ADOC and MHM’s awareness of these prisoners’ acute needs, the most severely mentally ill have been receiving grossly inadequate care; in fact, one of the experts described ADOC’s mental-health units as operating “almost exactly the same way” as segregation, as illustrated by the placement of segregation inmates without mental-health needs in the same unit and the inadequate out-of-cell time and treatment. Haney Testimony at vol. 2, 104.

a. Improper Use of Mental-Health Units

ADOC has had a persistent and longstanding practice of placing segregation inmates without mental-health needs in mental-health units. This practice allows prisoners without mental-health needs to occupy beds that should be reserved for prisoners who have heightened mental-health care needs and seriously undermines the therapeutic purpose of the mental-health units. Starting in 2012 and continuing through 2016, in its yearly contract-compliance reports, quarterly continuous quality improvement (CQI) meetings, and monthly operating reports, MHM repeatedly discussed ADOC’s problematic placement of segregation inmates in the RTU and SU. ADOC’s own audit of the Donaldson RTU in 2013 also identified the presence of segregation inmates without mental-health needs as a problem. While Associate Commissioner Naglich testified that segregation inmates were moved out of the Bullock SU by the end of 2013, evidence showed that the problem continued through 2016. For example, Brenda Fields, a clinical operations associate from MHM’s corporate office, testified that the presence of segregation inmates in the RTUs and SUs was noted as a problem in early 2016. Most recently, in December 2016, the list of prisoners in the Donaldson RTU included 13 segregation prisoners who did not have a mental-health code appropriate for mental-health units. PI. Ex. 1264, December 2016 Donaldson Segregation List (doc. no. 1099-8) at 14; Cul-liver Testimony at_

Dr. Tytell, ADOC’s chief clinical psychologist, explained that wardens place *1213 segregation inmates in the RTU or the SU when they do not have space for them elsewhere. He explained that MHM currently is expected to contact him or Nag-lich whenever this happens, but did not confirm whether this was always the case. Nevertheless, according to Tytell, the problem has been recurring. He conceded that it is ultimately the wardens, rather than the mental-health staff, who decide how cells in the mental-health units are used.

As all experts, MHM providers, and Dr. Tytell agreed, placing segregation inmates in a mental-health treatment unit is highly problematic. The reasons are multifold. First, having segregation inmates in the same unit as mental-health patients creates a security risk for mental-health patients: the segregation inmates’ presence prevents programming from taking place and diverts correctional officers’ attention away from mental-health patients and their needs. MHM’s medical director Dr. Hunter testified that'housing segregation prisoners in mental-health units compromises mental-health treatment, and that he has made this clear to ADOC. Dr. Woodley, MHM’s chief psychologist, informed ADOC that the presence of segregation inmates in the Bullock SU “undermine[s] the utility of this unit making it nearly impossible to operate it for its intended purposes.” Joint Ex. 323, February 2016 MHM Monthly Operating Report (doc. no. 1038-668) at 23.

Second, as Dr. Tytell and other experts explained, because mental-health inmates are particularly vulnerable, and those placed in segregation generally have behavioral problems, the presence of segregation inmates increases mental-health patients’ risk of being victimized through manipulation or violence. MHM and Dr. Tytell were aware of this risk, as one of the MHM staff members explained during a CQI meeting that using the Bullock RTU as a “disciplinary dorm” is “putting our vulnerable [inmates] at risk.” PI. Ex, 717, July 2015 Quarterly CQI Meeting Minutes (doc. no. 1044-11) at MHM029600. Associate Commissioner Naglich also agreed that segregation inmates in mental-health units can cause tension within the unit and anxiety to mental-health patients.

The housing of segregation inmates in mental-health units also contributes to the shortage of SÚ cells for those who actually need urgent mental-health treatment. Associate Commissioner Naglich acknowledged that patients awaiting SU admission could be in an “emergency” situation, as these patients require the highest level of care available within ADOC. Naglich Testimony at vol. 1, 208. However, since 2011, the Bullock SU has had a backlog of patients awaiting admission. While Naglich maintained that after the 2013 audit, ADOC actually moved all segregation inmates out of the Bullock SU in order to alleviate the backlog, she was unable to produce any documentation supporting her testimony. (During her testimony Naglich reassured the court that she could produce documents showing that she did move segregation inmates out of the Bullock SU in 2013. However, when she did bring in documents purportedly showing such transfers, none of them actually shoyred that any segregation inmates 'were moved out of the SU.) Moreover, in 2016, MHM continued to report that segregation inmates were still present in the SU, and that SU cell shortages were causing delays for patients who need SU-level care. Clearly, the placement of segregation inmates in SU beds continues to affect the most severely ill.

b. Inadequate Out-of-Cell Time and Programming

ADOC’s mental-health units often fail to serve their' therapeutic purpose due to in *1214 sufficient out-of-cell time and scarce programming for their patients. One of the plaintiffs’ experts, Dr. Haney, who for multiple decades has studied isolation and segregation in correctional facilities, noted that ADOC’s ‘celled’ mental-health units 39 resemble and operate like segregation units. 40 Experts on both sides pointed to specific traits of ADOC’s mental-health units that contribute to this segregation-like atmosphere and the lack of a therapeutic milieu: the presence of segregation inmates within the mental-health units, as explained above; a severe lack of out-of-cell time; and a lack of meaningful treatment activities.

Out-of-cell time is crucial for patients housed ,iri mental-health units. Without bringing patients out of their cells for counselling sessions, treatment team meetings, group sessions, and activities, placement in a ‘mental-health unit’ does no good for patients who need the highest level of care; careful observation and treatment cannot happen when confined in a small cell all day. In fact, without out-of-cell time and effective treatment, housing severely mentally ill prisoners in a mental-health unit is tantamount to “warehousing” the mentally ill. See Wyatt v. Aderholt, 503 F.2d 1305 , 1309 n.4 (5th Cir. 1974) (affirming the district court’s finding that a state mental hospital was functioning as a “ ‘warehousing institution ,.. wholly incapable of furnishing treatment to the mentally [ill] and ... conducive only to the deterioration and debilitation of the residents’ ”)(quoting Wyatt v. Stickney, 344 F.Supp. 387, 391 (M.D. Ala. 1972) (Johnson, C.J.)). Furthermore, as Dr. Haney explained, out-of-cell time is especially important for mentally ill, prisoners for two reasons. First, mentally ill prisoners experience more pressure and stress from a confined environment, and they have a more acute need to relieve that type of stress due to their vulnerable mental state; in other words, isolation makes it mor¿ likely that their conditions will deteriorate. In that sense, out-of-cell time is in and of itself therapeutic. Second, out-of-cell .time ensures that mental-health patients’ socialization skills do not atrophy to the point that they become uncomfortable with human interaction altogether.

Patients housed in ADOC’s- mental-health units receive very little out-of-cell time. This puts them at a substantial risk of continued pain and suffering, decompen-sation, and self-harm. As Dr.. Haney observed, at the Donaldson RTU, patients with serious mental illnesses are left inside their cells virtually all day, with no daily activities; this is similar to ADOC’s treatment of segregation inmates, whose out-of-cell time at ADOC does not exceed five hours per week. Dr. Burns concluded, and the court agrees, that the-RTUs and SUs offer “little treatment except for psychotropic medication due to staffing level shortages of both treatment and custody staff.” Burns Testimony at vol. 1, 26. Dr. Haney also noted that an unduly harsh and punitive practice limiting property makes mental-health units far from therapeutic and exacerbates prisoners’ idleness. He observed that mental-health unit inmates *1215 are allowed very little property, which means that they do not have books to read or other things to keep them engaged while spending the vast majority of their time in their cells. The court also observed firsthand the-idleness of seriously mentally ill prisoners during its visits to Bullock and Donaldson’s mental-health units: the majority of prisoners in those units were lying in their cells, often in a fetal position and facing the wall; there appealed to be np way to engage in .any remotely meaningful activity in the cell.

Dr. Patterson, the defense mental-health expert, testified that, in prisons around the country, the standard out-of-cell time for those in mental-health units is ten hours of structured therapeutic activity and - ten hours of unstructured activity per week. While a standard practice within the industry does not necessarily set the constitutional floor, a substantial deviation from the acceptable professional standard could support a finding of an Eighth Amendment violation. Steele, 87 F.3d at 1269 .

Patients in ADOC’s RTUs and SUs get a vanishingly small amount of time outside their cells compared to the standard practice. In 2013, MHM acknowledged that the lack of programming was problematic for the Bullock SU, telling ADOC that “[i]n-creased programming will assist in staffs ability to stabilize inmates sooner and address the waiting list problem thus easing the bottleneck.” PI. Ex. 689, MHM Corrective Action — Donaldson May 2013 (doc. no. 1069-6) at 13-14. As of June 2016, three years after the 2013 audit, patients in the SU at Bullock were still getting about 30 minutes of individual therapeutic contact per week and about 2.5 hours of non-therapeutic group contacts per week. Joint Ex. 346, June 2016 Monthly Operating Report (doc. no. 1038-708) at 4, 41

Prisoners in RTUs do not fare much better than in the SUs: Dr. Patterson found that RTU programming — which provides prisoners’ main opportunity to leave their cells — is inadequate. 42 MHM and ADOC’s internal documents also recognized this lack of out-of-cell time for RTU inmates in the 2013 Donaldson audit: the audit results revealed, that no groups were being held -for Donaldson RTU patients, and that providers were having difficulties keeping appointments due to correctional staffing shortages. MHM’s corrective-action plan following the audit stated that “ADOC not enforcing-the out of cell time and not supporting MHM' with the process” is a challenge in ensuring that RTU patients are let out of their cells daily. PI. Ex. 689, MHM Corrective Action — Donaldson May 2013 (doc. no. 1069-5) at 12. The problem of inadequate out-of-cell time at the Donaldson RTU has' continued in spite' of the corrective-action plan: in early 2016; MHM’s corporate office recommended “continued advocacy for RTU patients to receive outdoor recreation,” PI. Ex. 115, 2016 Contract-Compliance Report (doc. no. 1070-5) at 15. As of September *1216 2016, Donaldson RTU patients were getting fewer than two group contacts per week on average. Joint Ex. 344, September 2016 Monthly Operating Report (doc. no. 1038-703) at 3.

In addition to the lack of general out-of-cell time, mental-health units also fail to provide an adequate amount of treatment to these severely mentally ill prisoners because of shortages of mental-health staff. MHM’s program director Houser testified that groups have not been taking place at many facilities, including RTUs and SUs; indeed, an alarmed site administrator at Donaldson informed Houser in August 2015 that staffing losses at the facility have made it all but impossible to meet the needs of patients at the RTU. In December 2015, Houser asked Dr. Hunter to have one of the psychiatric providers at Bullock, Dr. Edward Kern, provide more services in the RTU in addition to his work in the SU. Dr. Hunter responded that, because the SU was so short-staffed and needed to be prioritized, shifting resources to the RTU would be difficult; he also noted that Dr. Kern had returned after a week of vacation to “what was essentially a zoo on [the SU].” PI. Ex. 382, Email from Houser to Hunter (doc. no. 1112-6). The 2013 Donaldson audit also found that the psychiatric coverage was insufficient and the logs for RTU rounds by providers were not being kept, making it impossible to tell whether RTU patients were getting any check-ins or treatment or whether their progress was being monitored. PI. Ex. 689, MHM Corrective Action — Donaldson May 2013 (doc. no. 1069-5) at 1-2.

The correctional staffing shortage also affects the amount of therapeutic care that patients at Donaldson and Bullock receive. Houser admitted that a lack of officers for the RTUs and SUs often cause the cancellation of group activities. The impact of the officer shortage was also consistently documented by ADOC and in reports that were sent to Associate Commissioner Naglich and OHS for their review. For example, during OHS’s 2013 audit of Donaldson, the auditors noted numerous deficiencies caused by the correctional staffing shortage. First, mental-health staff were manning laundry and showers instead of providing mental-health care, because there were not enough correctional officers to perform those basic duties. Scheduled activities and out-of-cell time were not being provided due to the correctional officer shortage, and MHM’s corrective-action plan stated that the “[RTU] has to be conceptualized as an RTU and not as segregation.”, PI. Ex. 689, MHM Corrective Action — Donaldson May 2013 (doc. no. 1069-5) at 9. The same was true at the Bullock SU: the problem of ‘access to patients’ — meaning that mental-health staff were unable to provide treatment to patients due to correctional officer shortage — was first identified in 2013, and then again in 2014 and 2016 contract-compliance reports. See PI. Ex. 114, 2013 Contract-Compliance Report (doc. no. 1070-4); PI. Ex. 105, 2014 Contract-Compliance Report (doc. no. 1070-3); PI. Ex. 115, 2016 Contract-Compliance Report (doc. no. 1070-5). As Naglich testified, because there are simply not enough correctional officers, the problem of accessing patients in RTUs and SUs recurs on a regular basis, even when it has been temporarily alleviated through reassigning officers to particularly problematic areas. As a result, patients in the SU often receive their individual psychiatric contact via cell-front check-ins. As explained earlier, this utter lack of confidentiality negates the therapeutic utility of these contacts. Such cursory contacts with the most severely ill patients are gravely inadequate.

The severe effects of warehousing, rather than treating, seriously mentally ill prisoners was crystalized in two incidents at the Donaldson RTU, where two different *1217 patients set their cells on fire out of frustration about not getting let out of their cells. The internal email reporting one of the incidents explained that the problem of not letting patients out of their cells was due to correctional staffing shortages. PI. Ex. 518, January 22, 2016 Email from Wynn-Scott to Houser (doc. no. 1112-18).

Jamie Wallace’s last 10 days in the Bullock stabilization unit further exemplify the inadequate treatment provided to the most severely ill patients: his medical records for his final 10 days reflected no group activities, one cell-side treatment plan note, and two psychiatric progress notes.

The lack of out-of-cell treatment in mental-health units adds the risk of harm posed by the harsh effects of isolation to that posed by inadequate treatment in general. As Associate Commissioner Nag-lich admitted, inadequate treatment of patients in inpatient units can lead to “additional exacerbation of their mental health symptoms,” including further hallucinations and delusions, and suicide. Naglich Testimony at vol. 3, 144-45. In addition, as experts testified, mentally ill prisoners are at a substantial risk of decompensating and being subject to prolonged pain and suffering when placed in an isolated environment. In other words, ADOC’s failure to provide adequate treatment and out-of-cell time in mental-health units forces the most severely mentally ill patients to face yet another risk factor for decompensation, even though their placement was for the specific purpose of alleviating the symptoms of their mental illness. Inadequate out-of-cell time and treatment in this context therefore compounds the risk of harm that is already inherent in a nonfunc-tioning mental-health care system,

c. Lack of Hospital-Level Care

ADOC also creates a substantial risk of serious harm to prisoners at the most severe end of the mental-health spectrum, because it does not provide hospital-level care or a hospitalization option for prisoners housed there. According to experts from both sides, hospital-level care or hospitalization should be available when patients pose a danger to self or others and interventions in the SU do not improve their condition: due to the harmful effect of isolation in an SU cell, staying in the SUs cannot be a long-term solution for patients who experience repeated episodes of deterioration.

Although many ADOC prisoners require hospital-level care, very few actually receive it. Virtually all psychiatric providers who testified agreed that they knew or noticed ADOC prisoners who needed to be transferred to a hospital. ADOC’s administrative .regulations dictate that those who are kept in the SU for over 30 days without stabilizing should be considered for hospitalization; the same provision also mandates that the treating psychiatrist recommend a transfer to a state psychiatric hospital if the treatment team determines that all mental-health interventions possible within ADOC have been exhausted, and that the inmate has not responded to those interventions. Joint Ex. 138, Admin. Reg, § 634, Transfer to State Psychiatric Hospital (doc no. 1038-168). However, ADOC virtually never transfers patients to hospitals, except in the case of prisoners nearing the end of their sentence. Dr. Hunter and Associate Commissioner Naglich corroborated this point, and Dr. Kern could recall only four prisoners in the last six years who were transferred to a hospital before the end of their sentences. Dr. Kern explained that MHM tries to deal with acutely ill patients’ symptoms within ADOC even though ADOC cannot provide hospital-level care, instead of pursuing hospitalization as required by the administrative regulation, because the waiting list for a bed in a hospital can be six months long or longer.

*1218 Several factors differentiate hospital-level care from what is provided in ADOC, as defense expert Dr. Patterson explained. Hospitals are able to offer a high level, of monitoring for suicidal and decompensat-ing patients while not isolating them in a cell: hospitals, or hospital-like environments are better at treating severely mentally ill patients because patients can leave their rooms to request help from staff, instead of having to wait until correctional officers or mental-health staff check on them; most of the patients’ interactions in a hospital are based on doctor-patient or nurse-patient relationship's, rather than guard-prisoner relationships; and the goal of the staff is to treat the patients, rather than to incarcerate them. Dr. Kern' also admitted that dealing with patients who need hospital-level care within an SU or RTU is challenging because in those units, providers have a very limited ability to give patients out-of-cell time. He also added that, if he could, he would like to- have SU patients “four to six, possibly eight hours out of their cell every day,”, but that this is impossible because “there are not enough security staff.” Kern Testimony at 21-, In other words, without a hospitalization option or another method of providing hospital-level care, the providers are forced to choose between the benefits of close, monitoring and restriction of activity and the harmful effects of isolation and losing socialization opportunities.

Both Dr. Patterson and Dr. Burns expressed strong disapproval of ADOC’s failure to provide hospital-level care. As Dr. Burns put it, waiting for an unstable patient’s end of sentence to transfer him or her to a hospital is akin to “someone with chest pain who has to wait until they’re released from prison to get taken to a hospital to have the chest pain treated. We wouldn’t do-that in the case of chest pain. I’m not. sure why we do it in the case of inmates with serious mental illness.” Burns Testimony at vol. 1, 168-69. Dr. Patterson opined that there, should be a hospital-like setting or actual hospitalization of patients with the most severe cases of mental illness; he did not see any hospital-like environment within the ten facilities he toured. He also explained .that placement in the stabilization unit, the highest level of care available within ADOC, should be a time-limited treatment intervention, because the SU is a highly isolated setting and likely to exacerbate conditions of those prisoners experiencing acute symptoms; and that if a patient is not stabilized in the SU, the patient should be moved to a hospital. Patterson emphatically stated, without any qualification, that refusing to transfer patients to mental health hospitals until the end of their sentences is simply “wrong,” 'and that it puts the most severely ill patients at a substantial risk of harm, Patterson Testimony at vol. 1, 174. In other words, for the most severe cases of acute mental illness, there is no alternative to a hospital setting, due to these stark differences in treatment options and milieu.

The grave risk of serious harm in failing to provide hospital-level care to severely ill prisoners was quite obvious in the case of Jamie Wallace. Less than two months before he testified in court, clinicians recommended that Wallace be transferred to a hospital. Despite the clinical recommendation, ADOC chose not to pursue hospital admission. In court, Wallace testified that voices in his head told him to kill himself; and indeed, he had attempted suicide multiple times. After testifying in court, highly agitated and destabilized, Wallace languished in a crisis cell and an SU cell before ending his life. Less than two weeks had passed since his testimony, regarding inadequate mental-health care in ADOC.

6. Inadequate Suicide Prevention and Crisis Care

Like its inpatient care, ADOC’s suicide-prevention procedures and crisis care suf *1219 fer from serious deficiencies. Identification, treatment, and monitoring of those who have heightened suicide risks are important because they provide the last safety net before the worst possible outcome in mental-health care: suicide. Reflecting its importance, courts have held that a minimally adequate mental-health care system must have a functioning suicide-prevention program. See, e.g., Ruiz v. Estelle, 503 F.Supp. 1265, 1339 (S.D. Tex. 1980) (Justice, J.) (“[I]dentification, treatment, and supervision of inmates with suicidal tendencies is a necessary component of any mental health treatment program.”), aff'd in part, rev’d in part on other grounds, 679 F.2d 1115 (5th Cir. 1982), opinion amended in part and vacated in part, 688 F.2d 266 (5th Cir. 1982), cert. denied, 460 U.S. 1042 , 103 S.Ct. 1438 , 75 L.Ed.2d 795 (1983); Madrid v. Gomez, 889 F.Supp. 1146, 1258 (N.D. Cal. 1995) (Henderson, C.J.) (adopting the suicide-prevention program standard from Ruiz as part of “constitutional minima”); see also Greason v. Kemp, 891 F.2d 829, 835-36 (11th Cir. 1990) (‘Where prison personnel directly responsible for inmate care have knowledge that an inmate has attempted, or even threatened, suicide, their failure to take steps to prevent that inmate from committing suicide can amount to deliberate indifference.”); Waldrop v. Evans, 871 F.2d 1030, 1036 (11th Cir. 1989) (finding that failure of a prison staff member to notify competent authorities regarding the inmate’s dangerous psychiatric state and self-harm may constitute deliberate indifference).

Prisoners are at an elevated risk of suicide due to the conditions prevalent in ADOC facilities. As Dr. John Wilsbn, the psychologist from MHM’s national Clinical Operations Department, explained to MHM’s program director Houser, “[experience and research confirm” the following: “Suicides increase with crowding, drugs, assaults, low staffing rates, lack of meaningful programming, and significant changes in facility mission/population such that inmates are moving between facilities more frequently or are uncertain about whether they will be housed or ... when there is basic unrest at a systems level, it can cause a spike.” PI. Ex. 1224, October 1, 2015 Email from Wilson to Houser (doc. no. 1117-24) at ‘2. Given the widespread presence of these factors in ADOC, the need for effective suicide prevention and crisis care cannot be overstated.

Suicide prevention consists of assessing and managing suicide risk: "assessing the risk entails using a suicide risk-assessment tool to identify those who are at heightened risk and the level of that risk; managing the risk involves both short- and long-term care that provides meaningful therapeutic contact to alleviate suicide risk. Suicide prevention also involves physically restricting suicidal prisoners’ ability to harm themselves. The short-term care provided to prisoners who are undergoing acute mental-health crises is called ‘crisis care.’

The standard of care in correctional mental-health care and ADOC regulations require that a suicidal'prisoner be placed in a special ■ cell that, minimizes risks of self-harm and suicide. These ‘crisis cells’ or ‘suicide-watch cells’ must be free of structural designs that would facilitate self-harm or suicide attempts, such as tie-off points where prisoners can tie a ligature to hang themselves; they also must be free of items that prisoners can use to harm themselves, such as sharp items and ropes. Patients on.suicide watch are stripped of personal belongings and regular clothes and given a suicide-proof blanket and a suicide smock.

Both correctional officers and mental-health staff have the ability to place any prisoner on suicide watch, after which a mid- or high-level provider is required to *1220 conduct a thorough mental-health assessment that includes the use of a suicide risk-assessment tool. 43 While on suicide watch, patients are to receive a high level of care in order to resolve the crisis and return to a less isolated and restrictive setting as soon as possible; such care includes close monitoring, daily re-evaluation of treatment plans, and frequent contacts with mid- or high-level providers such as psychiatrists and psychologists. If a patient on suicide watch is not stabilized within 72 hours, mental-health staff is required to evaluate the patient for admission to the stabilization unit. Discontinuing suicide-watch procedures requires an order from a psychiatrist, psychologist, or a nurse practitioner after an in-person evaluation.

ADOC prisoners in crisis may alternatively be placed in a crisis cell on mental health observation (MHO). MHO refers to a similar, short-term monitoring status for patients whose conditions are not as acute as those on suicide watch but still merit an observational status, or who have been recently released from suicide watch. Patients on MHO may be released only by a psychiatrist, psychologist, or nurse practitioner, but — unlike in suicide watch — the patients are allowed regular clothes and limited property.

ADOC’s suicide-prevention efforts and crisis care suffer from multiple inadequacies. First, ADOC and MHM’s use of a suicide risk-assessment tool is too limited to adequately identify those at high risk. Moreover, many prisoners at heightened risk of suicide or self-harm do not receive crisis care because of a severe shortage of crisis cells and staffing, and due to a culture of skepticism towards threats of suicide. Second, suicidal prisoners are often placed in unsafe environments both because of the shortage of crisis cells and because many crisis cells contain unsafe physical structures, such as tie-off points, and dangerous items that can be used for self-harm. Third, prisoners who are identified as suicidal receive inadequate monitoring and treatment. Lastly, inappropriate releases from suicide watch and a lack of follow-up care often push suicidal prisoners back into crises again and again, driving up the demand for crisis cells and diverting resources away from day-to-day, long-term treatment.

ADOC’s inadequate crisis care and long-term suicide-prevention measures have created a substantial risk of serious harm, including self-harm, suicide, and continued pain and suffering. ADOC has experienced a dramatic increase in suicide rates in the last two years. Alabama’s reported suicide rate was five per 100,000 between 2000 and 2013; by fiscal year 2015-2016, the rate had shot up to over 37 per 100,000. This is more than double the national average of 16 suicides per 100,000 prisoners in state and federal correctional systems. Patterson Testimony at vol. 2, 27; see also U.S. Department of Justice, Bureau of Justice Statistics, Mortality in Local Jails and State Prisons, 2000-2013 — Statistical Tables (2015) at Table 28. In the fiscal year starting in October 2016, the rate is projected to be over 60 per 100,000, based on the first three months of the year. See PL Ex. 1267, 2015-2016 Chart of ADOC Suicides (doc. no. 1108-38). Defense expert Dr. Patterson testified that he does not know of any prison system that has a suicide rate over 25 or 30 per 100,000. It is in the context of the magnitude of the *1221 suicide rate at ADOC that the court now considers ADOC’s failure to provide a functioning suicide-prevention system,

a. Failure to Provide Crisis Care to Those Who Need It

ADOC fails to provide suicide-prevention services and crisis care to many prisoners who need it. This failure stems from inadequate identification of those who are at heightened risk of suicide, combined with a culture of cynicism toward prisoners’ threats of suicide and self-harm and a severe shortage of crisis cells. The majority of suicides in ADOC are committed by prisoners who are not on the mental-health caseload, which means that many of the prisoners’ needs were never identified through the intake or referral process, and no intervention happened before their deaths. See PL Ex. 1267, 2015-2016 chart of ADOC suicides (doc. no. 1108-38) (showing eight out of 11 suicides between September 2015 and December 2016 committed by those who were not on the mental-health caseload).

According to correctional mental-health experts on both sides, the administration of a suicide risk-assessment and management tool by a qualified provider is widely recognized to be an essential part of mental-health care: it should be used as a part of the intake screening process and whenever a prisoner threatens or attempts to harm himself or actually does so. The purpose of a suicide risk-assessment tool is to assess whether a prisoner presents an increased risk of suicidal behavior in order to manage that risk through early intervention. As defense expert Dr. Patterson explained, the suicide risk-assessment tool must be completed in a face-to-face encounter by a high-level provider or a mid-level provider with high-level supervision, because the tool comes with clinical guidelines and requires clinical judgment.

ADOC and MHM did not use a suicide risk-assessment tool for many years and only recently began using one only at intake. While examining ADOC’s mental-health care in connection with this case, defense expert Patterson noticed that no suicide risk-assessment tool was being used, even though MHM had such a tool. Dr. Patterson recommended that a risk-assessment tool be used throughout the system, including at intake, upon placement in a crisis cell, and any other time a prisoner is deemed to have a heightened suicide risk. He also specifically indicated that a casual assessment without using a form is not acceptable — a form with appropriate clinical guidelines should be used in each instance.

As a result of this exchange, which took place in the summer of 2016 — more than two years after this lawsuit was filed— MHM began using a suicide risk-assessment tool at intake for new prisoners entering ADOC. 44 However, contrary to Patterson’s recommendations, MHM is not using the assessment tool when prisoners threaten or engage in self-harm or are placed in crisis cells. For example, Dr. Patterson found no suicide risk assessment had been completed for plaintiff Jamie Wallace in December 2016 despite his repeated threats of self-harm and suicide and his stay in a crisis cell shortly before he killed himself. Prisoners who threaten suicide frequently do not receive any kind of face-to-face assessment by high-level providers, let alone one involving a risk-assessment tool. The failure to perform proper suicide risk assessments to identify prisoners with a heightened risk of suicidal behavior places seriously mentally ill prisoners at an “obvious,” substantial risk of serious harm. Burns Testimony at vol. 1, 63.

*1222 A chronic shortage of crisis cells also contributes to ADOC’s failure to provide crisis care to those who need it. While the exact number of crisis cells sufficient for any given prison system depends on'the needs of the population and the treatment options available, it is clear that the number of crisis cells in ADOC is grossly inadequate. Witness after witness — including Associate Commissioner Naglich and MHM managers — agreed that having two crisis cells for 3,800 prisoners at the Sta-ton-Draper-Elmore complex, two crisis cells for 1,900 prisoners at Bibb, and two crisis cells for 2,700 prisoners at Fountain, is insufficient. 45 MHM’s medical director Hunter testified that the number of crisis cells in each of the 15 major facilities within ADOC is insufficient. In addition to the low-number of crisis cells across the system, the backlog of placements at the Bullock stabilization unit has contributed to the shortage: when the SU does not have a bed for the most acutely ill prisoners, often due to the presence of segregation inmates, mentally ill prisoners end up staying in crisis cells for much longer than 72 hours, though the explicit purpose of crisis cells is to serve as a short-term placement while the prisoner stabilizes. 46

Because ADOC has a limited number of cells to work with, ADOC and MHM staff gamble on-which prisoners to put in them and-frequently-discount prisoners’ threats of self-harm and suicide, instead of properly evaluating suicide threats by having a qualified provider administer a suicide risk-assessment tool. For example, in CQI meetings and multidisciplinary staff meetings, MHM staff discussed “cabling] their bluff” and “tak[ing] thé gamble” on prisoners who threatened to commit suicide or severely injure themselves. PI. Ex. 720, February 2014 Quarterly CQI Meeting Minutes (doc. no. 1044-14) at MHM029579; see also PI. Ex. 718, April 2015 Quarterly CQI meeting minutes (doc. no. 1044-12) at MHM029570 (discussing concerns about *1223 feigning suicidality to avoid being sent to segregation and that it is ADOC’s responsibility to find a safe place for “genuinely suicidal inmates” (emphasis in original)). Discussions during these meetings included statements such as “99 % often do not act on their threats.” PI. Ex. 721, January 2015 Quarterly CQI meeting minutes (doc. no. 1044-15) at MHM029614. Staff meeting minutes and medical records of patients also included conclusory statements suggesting that prisoners who are claiming suicidality and self-harm tendencies are in fact malingering or seeking ‘secondary gains’ — such as getting out of a segregation cell, or getting away from an enemy, or debt problems. In response to MHM staffs use of this type of language in medical records, MHM’s Chief Psychologist, Dr. Woodley, instructed staff to not use “malingering” and “secondary gain” in written documentation because one “cannot know [a prisoner’s] motivations for certain.” PI. Ex. 721, January 2015 Quarterly CQI meeting minutes (doc. no. 1044-15) at MHM029614. Contrary to this instruction, MHM staff continued to write off prisoners’ threats of self-harm as motivated by inmate-to-inmate debt or secondary gains, rather than conducting a proper assessment. In the March 2015 monthly operations report, MHM reported to ADOC that there have been “occasions where the inmate would not be placed on watch despite claiming to be suicidal, especially if the inmate is well known to the treatment staff as having a history of bluffing and/or no actual attempts.” Joint Ex. 328, March 2015 Monthly Operations Report (doe. no. 1038-673) at 14. A progress note from Jamie Wallace’s medical records dated five days before he committed suicide was representative of this culture: it noted that Wallace was “using crisis cell/threats to get what he wants.” Joint Ex. 496, Jamie Wallace Medical Records (doc. no. 1037-1062) at ADOC0399861. In sum, MHM staff frequently treat threats of self-harm as behavioral rather than mental-health issues, writing off threats instead of delving deeper to address underlying mental-health needs through a mental-health evaluation and suicide risk assessment. 47

This skeptical approach towards threats of self-harm poses substantial and obvious risks. First, those who should be on suicide watch may not receive the crisis care that they need and may kill or harm themselves. Gambling with threats of self-harm is dangerous: obviously, as experts and MHM staff agreed, not all prisoners who express suicidality are feigning it, and a number of prisoners do in fact become suicidal and engage in self-harm. Furthermore, the risk of misinterpreting a prisoner’s motivation is heightened by MHM’s failure to use a suicide risk-assessment tool after an instance or threat of self-harm. Second, hostile attitudes towards prisoners in mental health crises can “cause inmates to become more aggravated and agitated,” making it more difficult to treat the inmate. Houser Testimony at vol. 2, 160. Third, prisoners who make threats or engage in self-harm but are not actively suicidal may nevertheless suffer from underlying mental-health issues that need to be addressed.

As experts from both sides agreed, no bright line distinguishes ‘behavioral problems’ from ‘mental-health problems’: even if someone is engaging in self-harm for ‘secondary gains,’ a high-level clinician should evaluate the underlying mental- *1224 health issues, for four reasons. First, the presence of suicidality is not a yes-or-no question; according to the experts, it is well established that suicide risk is on a continuum, and a meaningful suicide-prevention program requires monitoring for an increased risk of suicide. Second, even in the absence of genuine suicidal ideation, engaging in self-harm is a mental-health issue because it indicates suffering from psychological distress and a lack of proper coping mechanisms to resolve problems. Therefore, insíéad of ignoring those who resort to self-harm to seek attention, staff should provide assistance. 48 Third, as Dr. Burns cautioned, chalking up instances of self-harm to behavioral problems not deserving of treatment may actually encourage such behavior: research in behavioral management shows that negative reinforcement of self-harm is more likely to prompt the prisoner to engage in more dramatic and even lethal self-harm. Finally, people who engage in self-harm can also accidentally kill or severely injure themselves without having a specific intent to do so; therefore, monitoring and assessment are necessary even if a prisoner’s suicidality is deemed not genuine.

To emphasize, the court does not mean to suggest that a prisoner must always be kept on suicide watch upon a threat of suicide; as experts noted, some threats of suicide or self-harm are not genuine. However, as the experts explained, these threats should not be written off without the use of an appropriate suicide risk-assessment tool by a qualified provider in a face-to-face evaluation. Based on the overall assessment of the evidence, the court finds that ADOC’s current practice was devoid of any system to ensure that suicidal prisoners are appropriately evaluated.

b. Placement of Prisoners in Crisis in Dangerous and Harmful Settings

Due to the chronic shortage of crisis cells, ADOC frequently places those on suicide watch in inappropriate environments, such as offices for correctional staff (also called ‘shift offices’), libraries, and segregation cells. These inappropriate placements put suicidal prisoners at a grave risk of self-harm and suicide.

ADOC and MHM have repeatedly placed suicidal prisoners in dangerous environments due to a lack of available crisis cells. MHM’s Dr. Hunter complained to ADOC in his March 2015 monthly operating report that ADOC officers at some facilities were placing prisoners on suicide watch in cells that are not crisis cells to avoid having to travel. He was also aware *1225 of at least a dozen times when prisoners in crisis at Bibb Correctional Facility were placed in shift offices over the weekend while waiting for transportation to another facility. ADOC’s Dr. Tytell recalled multiple instances in 2015 in which prisoners in crisis were being housed in shift offices for multiple days; he admitted that this practice was inappropriate but commented, “[Y]ou have to work with what you got.” Tytell Testimony at_During a 2016 ADOC tour, Dr. Haney found a prisoner who was housed in a mental-health office; 49 the prisoner had been there for over a day without receiving any treatment, even though he was deemed to be suicidal. Lastly, at least one documented case of suicide in the last three years occurred while a prisoner awaiting crisis-cell placement was housed in a room behind a shift office. 50 Houser Testimony at vol. 3, 55.

This practice of placing suicidal prisoners in unsafe environments increases the risk that prisoners will engage in self-harm, including suicide attempts. The consensus among the experts from both sides, as well as MHM and ADOC staff, was that housing a suicidal inmate in a space like a shift office is quite dangerous: not only are these places full of items that can be used for self-harm, but, depending on where the prisoner is placed, such placements can also cut off suicidal prisoners from the treatment that they desperately need.

Placing suicidal prisoners in cells that are either in or adjacent to death row or segregation also poses a number of problems. Holman Correctional Facility’s suicide-watch cells are located on death row. As plaintiffs’ expert Dr. Haney explained, the “juxtaposition of prisoners who are potentially suicidal with prisoners who are under a sentence of death” is “extremely problematic” for those in the throes of a mental health crisis. Haney Testimony at vol. 1, 101-02; Joint Ex. 459, Haney Expert Report (doc. no. 1038-1043) at 35. Defense expert Dr. Patterson agreed: bringing prisoners in crisis from general population into a death-row unit would make them more likely to decompensate, because death-row units are not designed to be therapeutic; moreover, death-row units are largely self-contained and are subject to their own regulations that are likely harsher and more punitive than the regulations in an ordinary unit. Dr. Patterson also expressed concern that death-row inmates would retaliate against inmates in crisis cells, creating even more stress for these vulnerable prisoners. 51

c. Inadequate Treatment in Crisis Care

The care provided to prisoners on suicide watch is also grossly inadequate. ADOC and MHM fail to provide adequate treatment to patients in crisis cells and, to make matters worse, frequently keep them in crisis cells for much longer than appropriate or necessary.

*1226 As Dr. Burns credibly opined, out-of-cell counseling sessions for prisoners on suicide watch are important both because they can help eliminate- suicidal thoughts and because they assist providers in meaningfully modifying treatment plans to address the causes of a crisis. However, prisoners on suicide watch -and mental-health observation are not consistently receiving out-of-cell appointments with counselors.

•Prisoners are frequently kept for extended periods of time in crisis cells, instead of being transferred to an-RTU' or SU for intensive, longer-term treatment. According to ADOC’s administrative regulations, anyone who is on suicide watch for more than 72 hours should be considered for placement in a mental-health unit. As experts on both sides agreed," crisis-cell placement is meant to be temporary and should not last longer than 72 hours, because the harsh effects of prolonged isolation in a crisis cell can harm patients’ mental health. However, since as far back as 2011, MHM has, by its own report, considered transferring prisoners- in crisis to treatment units only in a small fraction of the crisis • placements that last longer than 72 hours. See PI. Ex. 1190, 2011 Contract-Compliance Report (doc. no. 1070-8) at 22 (in 2011, only 20 % of those housed in crisis cells for over 72 hour's were considered for transfer); PI. Ex. 105, 2014 Contract-Compliance Report (doc. ho. 1070-105) at 11 (in 2014, 29 %); PI. Ex. 115, 2016 Contract-Compliance Report (doc. no. 1070-3) at 11 (in 2016, 13 %). MHM’s CQI manager testified that extended stays in crisis cells are “sometimes” necessary because there is a “full house” in the appropriate treatment unit. Davis-Walker Testimony at vol. 2, 102. See also PI, Éx. 1219, September 2014 Emails between MHM and ADOC (doc. no. 1047-10)(dis-cussing a prisoner who was on suicide watch for 25 days at Bibb, waiting for, a transfer to Bullock SU).

Contrary to the CQI manager’s characterization, documentary evidence showed that prisoners are in fact frequently kept in crisis cells for much longer than 72 hours. See PI. Ex. 721, January 2015 Quarterly CQI Meeting Minutes (doe. no. 1044-15) at 4- (showing examples of long crisis-cell stays, such 'as 240 hours at Limestone, 429 hours at Staton, and 620 hours at Ventress, and suggesting that weekend hours were not being counted); PI. Dem, Ex. 141, 2016 Crisis Cell Placements (doc. no. 1156-2) (showing that a-majority of facilities have multiple prisoners being housed in crisis cells for longer than 144 hours, some of them exceeding 200 hours, in 2016). At St. Clair, Dr. Haney confirmed that one of the prisoners he interviewed had been housed in a barren suicide-watch cell in the infirmary for five months — well beyond the intended duration of crisis-cell stays. These extremely lengthy stays in crisis cells contribute, in turn, to a shortage of crisis cells throughout the system. They also illustrate that prisoners are not getting the treatment they need to stabilize and be moved out of crisis cells, or that ADOC and MHM are leaving these mentally ill prisoners in extremely-isolated environments for longer than appropriate.

d. Unsafe Crisis Cells

Despite their purpose of preventing self-harm and suicide, crisis cells in ADOC facilities are unsafe. First, crisis cells are ridden with physical structures that provide easy opportunities to commit suicide. Experts from both sides agreed that having crisis cells free of tie-off points is a critically important feature of suicide prevention in prisons. The National Commission on Correctional Health Care (NCCHC), a professional organization that promulgates standards for correctional health care and provides accreditation to facilities that follow those standards, requires that crisis cells be free from tie-off *1227 points that can be used for self-injurious behavior. 52 ADOC’s history makes clear the critical importance of this issue: all but one suicide within ADOC in the last two years happened by hanging. However, many of ADOC’s crisis cells have easily accessible tie-off points, such as sprinkler heads, hinges, fixtures, and vents, making them incredibly dangerous for suicidal prisoners. In fact, defense expert Dr. Patterson stated that making crisis cells suicide-proof is the “number-one issue” to be addressed. Patterson Testimony at vol. 1, 296. •

Examples of unsafe crisis cells abound. As Dr. Haney noted and the court saw firsthand during prison visits in February 2017, in the Bullock SU, where some prisoners on suicide watch are kept, sprinkler heads are located directly above the sink and the toilet, making it easy for suicidal prisoners to climb up to tie a ligature on the sprinkler head. In fact, that is how Jamie Wallace committed suicide while housed in an SU cell at Bullock. As plaintiffs’ experts observed, crisis cells in St. Clair, Kilby, and Holman all have tie-off points; MHM’s Houser also admitted that many crisis cells across ADOC facilities are out of compliance with NCCHC standards for suicide cells because they have tie-off points.

Unsurprisingly, MHM staff have repeatedly expressed concerns about the safety of crisis cells in multiple facilities, as reflected in contract-compliance reports and CQI meeting minutes: in 2011, staff expressed concern about the unsafe features of crisis cells at Fountain; in 2012, staff reported concerns about the safety of Yentress crisis cells; in 2016, MHM’s contract-compliance report stated that crisis cells in Holman are unsafe because of the open bars on the doors. ■

Another dangerous aspect of many ADOC crisis cells is the difficulty of monitoring the prisoner inside. The design of the cell doors and windows and the layout of the facilities often prevent a direct line of sight into the cell. For example, Dr. Haney testified that suicide-watch cells at Donaldson, located in the infirmary and known as Z-Cells, had grates over the windows that made it very difficult to see into a cell even when standing directly in front of a door and peering in. At St. Clair, Dr. Haney noted that suicide-watch cells were located in a hallway in the infirmary; they, too, were hard to see into and easy to ignore. PI. Dem. Ex. 107, St. Clair Suicide Watch Cell (doc. no, 1125-62). Associate Commissioner of Operations Culliver noted that even though Holman crisis cells have barred fronts, it is nonetheless impossible to see into these cells from the officers’ cube located closest to them. Culliver also acknowledged that the solid crisis-cells doors at many facilities, including Bullock, Donaldson, Fountain, Kilby, and St. Clair, make it impossible for an officer or mental-health provider on the unit to see into the cells and check on the prisoners housed within them without walking up to the door and looking -through the small glass window.

ADOC’s practice of allowing prisoners in cells to cover the windows with paper or other material exacerbates the visibility problem. Dr. Haney noticed this practice in Donáldson, Holman, St. Clair, and Bibb, describing it as incredibly problematic be *1228 cause it blocks any type of monitoring entirely. Dr. Haney witnessed a particularly disturbing incident while touring Bibb. He entered the infirmary and went to speak with the prisoners housed in the crisis cells. As he was speaking to one, a lawyer touring the facility with him discovered that a prisoner in another crisis cell was, at that very moment, attempting to hang himself — the prisoner had somehow procured a cord to wrap around his neck and had attempted to cover the window with a blanket. Allowing prisoners to cover the windows of their cells is dangerous in any context, but it is particularly unacceptable for prisoners known to be suicidal. Due to the visibility problems with many ADOC suicide-watch cells, defense expert Patterson opined that suicidal prisoners should be under direct, constant observation while in those cells. He also explained that camera observation by an officer at the control station may not be sufficient, because by the time that officer notices a suicide attempt, it might be too late; moreover, the officer likely has other responsibilities that would preclude careful monitoring of any single cell.

The dangerousness of crisis cells and the significant risk of harm caused by such conditions are compounded by ADOC’s rampant failure to prevent introduction of dangerous items into crisis cells. Admittedly, the parties in 2014 reached a settlement that prohibits ADOC officers from providing disposable razor blades to prisoners on suicide watch and in segregation. See January 16, 2015 Order Denying Motion for Preliminary Injunction (doc. no. 84). 53 However, the problem of dangerous items in crisis cells has continued, according to a number of ADOC officials and MHM staff. Suicidal prisoners have access to inappropriate items — such as sharp implements — either because they bring the items with them when placed on suicide watch and correctional officers do not search them, or because correctional officers or inmate ‘runners’ who perform various housekeeping tasks around the unit bring the items to the crisis cells. MHM’s Houser stated that prisoners have access to improper items in safe cells at a number of facilities, including specifically Donaldson, St. Clair, Staton, and Holman; she was not sure whether this problem had been addressed at any of these facilities. Dr. Hunter of MHM and Associate Commissioner Culliver both testified that finding sharp objects in a suicide-watch cell has been a problem at Bibb, despite the installation of flaps on cell doors that were intended to stem the flow of contraband. Lastly, Holman’s crisis cells are particularly problematic, as Associate Commissioners Naglich and Culliver admitted: although passing prisoners are able to slip items to those housed in crisis cells at a number of facilities, this sort of exchange is particularly easy at Holman, where the crisis cell doors have open bars. Yet, when asked what MHM had done to address this issue, Houser responded that after each incident, MHM staff would “ask [ADOC] to please do a better job.” Houser Testimony at vol. 3, 16. She could not identify any other efforts either by MHM or ADOC to address this issue. 54

*1229 e. Inadequate Monitoring of Suicidal Prisoners

The unsafe features of crisis cells heighten the importance of monitoring prisoners for signs of decompensation or suicide attempts. However, ADOC’s •monitoring practices are woefully inadequate.

According to ADOC’s administrative regulations and the standard of care for mental-health care in prisons, suicide-watch checks should take place at staggered, or random, intervals of approximately every 15 minutes, rather than exactly every 15 minutes. For prisoners on mental-health observation, these staggered checks should occur approximately every 30 minutes. Staggered intervals prevent prisoners from timing their suicide attempts, because otherwise they can predict exactly when checks will occur. Such monitoring procedures are all the more crucial when suicidal inmates are housed in cells that have little visibility: as plaintiffs’ expert Vail bluntly stated, without regular checks, “[Y]ou have no idea if they’re alive or dead.” Vail Testimony at vol. 1, 96.

Dr. Burns and Dr. Haney both testified that many of the monitoring logs they had seen during their site visits and document review had pre-printed times or had handwritten pre-filled times at exact intervals. This practice reflects prison staffs lack of understanding that checks should be performed at staggered intervals, and makes it impossible to ensure that staggered checks are actually happening. Associate Commissioner Naglich admitted that staff are not permitted to use monitoring logs with pre-printed times, but that some continue to use them. She also testified that officers and staff are not permitted to handwrite times and signatures in advance of, or in lieu of, their actual checks. However, during the post-trial prison tours, the court came across multiple logs where times at 15- or 30-minute intervals had been pre-filled; even though the parties had agreed during the trial to correct this practice, and the court had ordered compliance with the agreement several weeks before the tours. This evidence of noncompliance greatly troubled the court, as it showed that policy changes are not being implemented on the ground eveq when a court order is involved.

For the most acutely suicidal, constant — rather than staggered-interval— watch is necessary. As Dr. Burns opined, correctional systems must have a constant-watch procedure for individuals whose risk of suicide is the highest, due to their engagement in self-injurious behavior or threat of suicide with specific plans: if a prisoner is waiting for an opportunity to kill himself, it is too dangerous to walk away, and he must be constantly observed. For this reason, the NCCHC standards classify constant-watch procedures as an “essential” standard, and MHM is contractually obligated to follow all NCCHC standards. 55

ADOC and MHM had not provided constant watch for acutely suicidal inmates prior to Jamie Wallace’s death. During the trial, in the wake of Jamie Wallace’s suicide, the court urged the parties to propose interim measures tó prevent more suicides. Plaintiffs then filed a motion for temporary restraining order seeking to institute constant wátch and other suicide-prevention measures. Plaintiffs’ Emergency Motion for Temporary Restraining Order (doc. no. 1075). The parties reached an interim agreement in early January. Phase 2A Interim Relief Order Regarding Sui *1230 cide Prevention Measures (doc. no. 1102). The agreement mandated a constant-watch procedure for those deemed acutely suicidal and forbade using pre-printed or pre-filled forms for other types of suicide watch. While defense counsel represented to the court that it was Commissioner Dunn’s intent to keep the constant-watch procedure until told otherwise by the court or experts, the court also heard testimony that the current implementation of suicide-prevention measures and constant watch is not sustainable. 56 The parties defined ‘constant watch’ as a “procedure that ensures one-on-one visual contact at all times, except to the extent that the physical design allows an observer to maintain an' unobstructed line of sight with no more than two people on suicide watch at once.” Interim Agreement Regarding Suicide Prevention Measures (doc. " ño. 1102-1). MHM’s Houser testified that the implementation has been difficult because some facilities do not have a layout conducive to constant watch, due to the location of the windows on cell doors and structures that obstruct a direct line of sight into crisis cells. As a result, MHM has had to transfer some prisoners to other facilities. Another obstacle in the implementation stems from a lack of sufficient correctional staffing: for example, the Holman crisis cells, located on death row, are unsafe for mental-health staff, because without sufficient correctional staffing on duty, .prisoners often throw objects from second and-third tiers at the mental-health staff conducting constant watch on the first tier. Finally, according to Houser, the annual budget fpr a permanent constant-watch procedure is projected to be-over $4 million, but MHM was initially provided only $200,000 to meet the immediate needs of the interim agreement mandating constant watch. 57

f. Inappropriate Release from Suicide Watch and Inadequate Follow-up

Prisoners are routinely released from suicide watch improperly and receive inadequate follow-up care after their release from suicide watch. These practices create a substantial risk of recurring self-injurious behavior and suicide.

As experts from both sides explained, suicidal prisoners should be released only with the approval of a psychiatric provider (psychiatrist or ' nurse practitioner) who has made a face-to-face assessment that their condition was sufficiently stabilized to warrant it. In 20Í6, MHM reported to ADOC that it was discharging patients from suicide watch without,a face-to-face assessment; the decisions were based instead on whatever information lower-level mental-health staff communicated over the phone to on-call doctors and nurse practitioners. A-nurse practitioner at'Donaldson and St. Clair testified that generally she will not authorize the release of a prisoner from suicide watch at St, Clair without seeing him in person; however, when she is not at St. Clair (a significant majority of the hours in the week), staff call Dr. Hunter to authorize the release remotely. A

This text is long and has been trimmed here. Open the source document for the complete record.