As the U.S. Supreme Court announced its decision regarding the Affordable Care Act, another landmark health care case was filed in federal district court. Baycote v. Federal Bureau of Prisons is a class action suit by inmates of the federal control unit (or “SuperMax”) facility in Florence, Colo. It was filed by attorneys from the Washington Lawyers’ Committee for Civil Rights and Urban Affairs with pro bono assistance from a private law firm. The federal prison, also known as ADX, provides the highest level of security in the federal prison system and is renown for the notoriety of its inmates such as Unabomber Ted Kaczynski and the late Oklahoma City bomber Timothy McVeigh.
The suit alleges multiple egregious violations of the Eighth Amendment prohibition against cruel and unusual punishment. Plaintiffs claim that correctional officers routinely were physically and emotionally abusive and that the facility failed to provide necessary mental health screening and treatment. The full suit covers more than a hundred pages and can be reviewed online. A recent three-part series of articles discussing the suit by Andrew Cohen was published simultaneously this week in the Atlantic.
The allegations in the suit are extremely serious. Inmates point to incidents in which they were shackled in four point restraints to a cement wall and denied food or bathroom privileges. They allege emotionally abusive tactics such as threats, humiliation, and mocking of mentally ill prisoners. When the plaintiffs filed administrative complaints, they allege that these internal complaints were “lost” or otherwise destroyed, and that the facility or system retaliated against them.
The Code of Federal Regulations prohibits the housing of mentally ill inmates in ADX. The regulations also require a mental health evaluation within 30 days of arrival, and every month after that, with provision of therapy or medication as needed. The Baycote suit alleges that the facility inappropriately housed ill inmates at Florence and that mental health services were inadequate for their care. It alleges perfunctory intake screening, non-confidential therapy sessions, failure to make a diagnosis or to consider diagnoses made at other facilities, and inappropriate discontinuation of medication. The suit also alleges that mental health staff improperly participated in law enforcement activities such as manning a gun tower, participating in cell extractions, and escorting prisoners while wearing a weapon.
The plaintiffs in this case are hardly model citizens. The lead plaintiff murdered a fellow inmate, another stabbed a witness in a courtroom, another attacked a prison chaplain, and one held a staff member hostage at knifepoint in another facility. The lawsuit implies that these actions were the result of untreated mental illness. Andrew Cohen, in the Atlantic series, casually dismisses their level of dangerousness as being “hardly noble.”
What the Atlantic articles and the Baycote complaint do not mention is the dilemma faced by the prison and prison clinicians when treating inmates like this. Inmates with severe antisocial personality disorder press the limits of our diagnostic criteria. People with severe personality disorders often have histories of trauma, cognitive deficits, co-existing mood disorders as well as learned maladaptive behaviors. Treatment options are limited, unproven, and likely to have a poor prognosis with each additional layer of pathology. At least one of these plaintiffs had been treated with a series of medications prior to transfer, which to me indicates heroic efforts to manage violence pharmacologically. The decision to stop medication at ADX could certainly be seen as a final recognition that medication was simply not the answer.
Reasonable clinicians at different facilities can legitimately disagree about treatment, and these disagreements should not be taken as evidence of neglect, abuse or abandonment. Security is also a necessary component of treatment for severe personality disorders, and a control unit environment can provide that security.
Similarly, a regulation that forbids housing of the mentally ill leaves the facility in a conundrum, a logical paradox in which the clinician has to negotiate a bizarre line of circular reasoning. If an inmate is eligible for ADX because of violence, and violence is indicative of severe mental illness which requires treatment, then by definition they cannot be housed in a control unit environment. This type of regulation is what drives correctional psychiatrists screaming into the night.
I agree that no inmate should be subject to abuse or neglect. My concern is that legitimate grievances and problems will be papered over with inflammatory prose. When attorneys and journalists refer to “unspeakable cruelty and wickedness” in connection with a facility or its clinicians, or fling about adjectives like “callous, inhumane, deplorable, barbaric, and torture,” we get caught up in controversy rather than focusing our efforts to improve services.