Dr. Kathryn Burns, chief psychiatrist for the Ohio Department of Corrections, testified that ADOC fails to identify many prisoners with mental problems when they arrive.

In most prison systems, Burns said, 20 to 30 percent of prisoners need mental health services. In Alabama, just 14 percent are listed as needing care. That likely means many people aren’t even eligible for therapy, she said.

In one case, shown in a 2015 email between top ADOC officials, a prisoner who tried to kill himself had attempted once before, in 2014. Despite two attempts, the prisoner was not on the mental health caseload and received no more care than a prisoner without any mental illness at all.

“It’s difficult to call this a system, because it misses people at intake and people can’t join,” Burns said. “This is the worst system I’ve ever seen.” Because of that initial failure, she testified, the system “falls apart at the front door.”

After intake, Burns and other experts testified, the treatment gets no better. Even those who are identified as needing mental health services are cared for by underqualified mental health staff. The psychotherapy they receive, if any, is rarely more than a superficial check-in. And the Department struggles to properly respond to inmates with mental health problems that cause harmful behavior.

Burns interviewed 77 prisoners and visited nine of the 15 Alabama prison facilities. In testimony that became especially important after Jamie Wallace’s death, she discussed the substantial risk of serious harm for suicidal prisoners who are observed only at 15-minute intervals rather than being observed continuously or at staggered intervals.

Burns also testified that during her tours of Alabama prisons, she saw isolation units where cell windows were covered with metal, letting in only “pinpricks of sunlight.” Some were occupied by prisoners who had been there for months and who would not respond when spoken to.

The dangers of segregation – essentially solitary confinement – were also highlighted by Dr. Robert Hunter, who is in charge of psychiatric services for the prison system.

Hunter, the chief psychiatrist and medical director for MHM, testified that a stint in segregation – or the prospect of facing one – is a common factor among inmates who have died by suicide in Alabama’s prisons.

“Any inmate in [segregation] is at risk of deterioration,” Hunter said. “I think, overall, the concept of segregation in corrections should be re-thought … it’s generally recognized that prolonged segregation is deleterious to a person’s mental health.”

When Hunter met with prison officials and MHM employees in October 2015 to discuss the rising number of suicides in Alabama prisons, solitary confinement was part of the discussion. Prison officials, however, never followed up and made no substantive policy changes. Hunter testified that more than a dozen prisoners had killed themselves between October 2015 and December 2016.

A prisoner identified in the trial as M.P. was held in segregation for six years. He testified about living in a “single-man cell” with an area smaller than a parking space. The cell had no central air during Alabama’s brutally hot summers. M.P. said he struggled with suicidal thoughts and survived several suicide attempts. In segregation, he testified, he heard voices in his head saying, “It’s not worth it. Give up.”

Trial testimony also revealed that prisoners receiving treatment don’t necessarily find themselves in a better situation. Dr. Craig Haney, a nationally renowned prison psychology expert who toured some of Alabama’s prisons, told the court he found that cells used to “treat” severely mentally ill prisoners – therapeutic cells – are indistinguishable from the harshest solitary confinement cells.

In fact, Haney said, the prison system so blurs the line between a therapeutic cell and a solitary confinement cell that it “conflates punishment and treatment in terms of the harshness of the conditions.” Overall, he told the court, the risk to mentally ill prisoners is “substantial and the harm is serious.”

Eldon Vail, the former head of Washington state’s prisons, testified that Alabama prisons are simply getting it wrong when it comes to dealing with prisoners who harm themselves. The proper response is to intervene with therapy, not discipline. Placing an inmate in segregation for self-harm will exacerbate the behavior, Vail said.

Many of the system’s failures – to provide proper psychotherapy, medication and a more appropriate response to self-harm – are rooted in the severe understaffing of Alabama’s prisons. Vail said the lack of ADOC security staff and overcrowding in general puts more stress on mental health patients and leads to inadequate treatment.

“If you don’t have enough staff to do the job, some things have to go,” he said.