Jay Lee Gates John Ronald Bertram v. Ron Shinn James Rowland Nadim Khoury, M.D., Assistant Deputy Director--Cdc Health Services Kenneth Shepard, Chief Deputy Warden for Cmf Clinical Nicholas Poulos, M.D., Daniel E. Thor, Chief Physician and Surgeon, Cmf Paul Morentz, Chief Psychiatrist--Cmf Outpatient Program H Md Bruce Baker a R Md, Chief Psychiatrist Northern Reception Center D. Michael O'COnnOr Douglas G. Arnold, Acting Director of the California Department of Mental Health Clyde Murrey, Acting Deputy Director for State Hospitals Sylvia R.N., Executive Director Dmh Vacaville Psychiatric Program Eddie Ylst
Docket: 94-17146
Court: Court of Appeals for the Ninth Circuit; October 16, 1996; Federal Appellate Court
Prison officials were found in contempt of court for not complying with a consent decree regarding adequate psychiatric care at the California Medical Facility (CMF), which serves mentally ill inmates. The consent decree mandated the development of an outpatient psychiatric program to provide "appropriate psychiatric evaluation and treatment," with a requirement for an interim program to be operational by June 30, 1990, and full implementation by October 31, 1990.
The case arose from a class action lawsuit challenging the adequacy of medical care at CMF, which has been under extensive judicial oversight. The plaintiffs, all incarcerated individuals with mental illnesses, argued that the facility's outpatient program did not meet the terms of the consent decree, as the prisoners, although designated as "outpatients," remained confined within the facility, differing from typical outpatient care.
Despite over $10 million spent on improvements, the court found the compliance efforts inadequate, necessitating more significant changes in staffing and treatment methods than what CMF was willing to implement. Following the failure to meet deadlines set by a mediator appointed under the consent decree, the prisoners sought to hold the facility's officials in contempt. A magistrate judge was tasked with overseeing the development of a revised outpatient psychiatric program plan in consultation with various stakeholders.
The mediator and experts proposed thirteen modifications to a prison psychiatric care plan, recommending contempt charges against prison officials for their rejection. The district court found these officials in contempt based on a consent decree that required appropriate psychiatric screening and treatment for inmates. The court acknowledged the challenges faced by the district judge and prison officials in providing adequate care, particularly for mentally ill inmates. However, it concluded that the term "appropriate" was vague and lacked specificity in the decree. The mediator interpreted "appropriate" as aligning with a "community standard of care," which the prison's chief psychiatrist disagreed with, stating such a standard for incarcerated individuals did not exist. The district judge supported the prison officials' view, declaring that the decree did not adopt a community standard and that the mediator's interpretation lacked valid criteria.
Despite this, the district court still found the prison officials in contempt, defining "appropriate psychiatric screening" and "treatment as medically indicated" in terms of a "clinical standard of care." This interpretation established a clinical standard for adequate psychiatric care based on professional standards rather than merely avoiding Eighth Amendment violations. Future compliance assessments regarding psychiatric evaluation and treatment will follow these established clinical standards, ensuring that the adequacy of care provided aligns with professional psychiatric norms.
The court held prison officials in contempt of court, mandating compliance with thirteen proposed modifications from mediators as part of its remedial powers. The judge stated that contempt findings allow the court to impose new requirements to fulfill the consent decree's original intent. Even without a contempt finding, enforcing the modifications was deemed appropriate. The prison officials faced civil contempt sanctions of $10,000 per day for non-compliance. A special master, appointed by the court, was tasked with overseeing the implementation of the modified outpatient plan and reporting any failures by the officials, which could trigger additional sanctions. The contempt order was stayed pending appeal.
The court addressed jurisdiction, countering the prisoners' claim of lacking jurisdiction due to the absence of a final order. It determined that the order was final under 28 U.S.C. § 1291 because the contempt adjudication and the special master's requirements represented significant consequences for the officials. Citing precedents, the court noted that a contempt finding coupled with sanctions constitutes a final decision for appellate review, despite the stay on monetary penalties. The court emphasized the need to balance the inconvenience of piecemeal review against the potential for justice delays, ultimately deciding that allowing the appeal was justified given the ongoing nature of the case and the implications of the contempt order.
Pragmatic considerations favor immediate review of the contempt order concerning the prison officials. The central issue is whether the consent decree adequately specifies the requirements for a contempt citation. The applicable provision mandates "appropriate psychiatric evaluation and treatment for all inmates at CMF as medically indicated." The prison officials argue that the decree lacked the necessary specificity to justify a contempt finding based on their alleged violations, which include inadequate psychiatric care in the outpatient program and repeated failures to meet mediation deadlines.
For the contempt order to be valid, it hinges on the existence of a clear violation of the decree. Specifically, the decree must be sufficiently detailed to warrant the thirteen proposed modifications to the outpatient psychiatric plan. Under Federal Rule of Civil Procedure 65(d), an injunction must clearly define the restrained actions in reasonable detail. Established case law confirms that specificity in consent decrees is essential for contempt findings.
Consent decrees, which are court-approved agreements rather than products of contested litigation, are treated as injunctions and must be interpreted strictly within their explicit terms. The meaning of the decree is confined to its text, ensuring that the intentions or purposes of the parties do not dictate its interpretation. The decree reflects a compromise between opposing interests, and the defendant's waiver of the right to contest the issues must be honored, requiring adherence to the decree's written language rather than hypothetical alternatives.
An injunction must clearly delineate prohibited or required conduct to be enforceable by contempt, as emphasized by the Supreme Court. The judicial contempt power can be misused if based on vague decrees, prompting Congress to mandate that federal court orders be sufficiently clear for compliance. In this case, the specificity of the consent decree is crucial, distinguishing it from the mediator's recommendations. The consent decree must explicitly instruct prison officials to provide a specified level of psychiatric care; otherwise, they cannot face contempt charges for failing to comply.
The court assumes the mediator's thirteen proposed modifications to the psychiatric care plan were specific enough to support contempt if they had been part of the consent decree. The core issue was the refusal of prison officials to implement these modifications, which the court determined fell under the consent decree's requirement for "appropriate psychiatric evaluation and treatment." The court reviews specific disagreements regarding these modifications, noting the prison officials’ stance, supported by Dr. Richard M. Yarvis's affidavits, that their approach was appropriate.
The prison officials suggested a coordinator for mentally disabled inmates, while the mediator recommended a dedicated team structure, which the prison's chief psychiatrist deemed excessively resource-intensive given the population of around fifty such individuals at the facility. Additionally, the mediator advocated for using clozapine, an antipsychotic medication, but the prison's psychiatric expert raised concerns about its safety and noted the availability of new medications with potentially lower risks.
The mediator recommended that the Facility implement specific treatment protocols for various psychiatric conditions, but Dr. Yarvis indicated a lack of consensus within the psychiatric profession regarding appropriate protocols for most conditions, with the American Psychiatric Association only agreeing on practices for depressive and eating disorders after extensive discussion. Dr. Yarvis argued it is unrealistic to expect the Facility's psychiatric staff to achieve consensus where a leading organization has not.
Prison officials expressed concerns that some of the proposed modifications, particularly group therapy programs, could be too dangerous given the violent history of many inmates. Dr. Yarvis highlighted the safety issues associated with treating a highly dangerous patient population, noting complications such as severe character pathology, treatment noncompliance, and inaccurate information from patients.
Prison officials criticized the August 1994 Plan for failing to consider the unpredictable and dangerous nature of many inmates in the outpatient psychiatric program, citing CMF's high inmate-to-staff assault ratio. They argued that the plan reflected a misunderstanding of the unique challenges posed by the inmate population, which necessitates a more secure environment than typical community mental health facilities.
The mediator proposed an annual requirement of twenty hours of continuing medical education for psychiatrists, which Dr. Yarvis deemed excessive compared to the four to five hours he considered adequate for psychopharmacological training.
The differing perspectives on the appropriateness of the proposed modifications illustrate a divide between prison officials and the mediator regarding medical necessity. The district court did not dismiss Dr. Yarvis’s views on appropriate psychiatric treatment nor did it clarify why the mediator’s approach was favored. The order granting control of the Facility to a special master raised concerns about appropriate deference to prison authorities, especially given that the inmate population includes both criminals and mentally ill individuals, complicating standard behavioral restraints.
Evidence presented by prison officials indicates that inmates with mental illness are more likely than non-criminal individuals to misrepresent their symptoms, misuse their medication, and engage in violence against themselves or others. This behavior reflects their prior inability or unwillingness to conform to societal norms, resulting in their incarceration. The specificity of the consent decree is crucial in determining who resolves disputes regarding psychiatric care standards. A more detailed decree could empower the district court to assess whether the prison's psychiatric practices meet established criteria. Without such specificity, the court lacks the authority to make determinations.
The interpretation of "appropriate psychiatric evaluation and treatment" as a "clinical standard" raises questions about its clarity in the context of psychiatric care within the prison system. The terms used, while seemingly professional, lack a demonstrated specific meaning relevant to this environment. Several interpretations of what constitutes a "medically indicated" level of care exist, including adherence to civil rights protections, comparisons with care levels in other facilities, and established medical standards or recommendations.
The ambiguity surrounding "appropriate" psychiatric care results in ongoing oversight of the prison system by the district court and its appointed officials, rather than allowing control to reside with state political processes and prison management.
The psychiatric care standard outlined in the consent decree is vague compared to other stipulated guidelines for specific diseases, such as asthma and tuberculosis, which require written, nonbinding treatment protocols. Mental illness is not included in this list, and the prison's psychiatric expert argues that established protocols are impractical, with consensus only on eating disorders and depression. The contempt order erroneously assumes that prison officials agreed to develop protocols for all mental illnesses. The decree mandates hiring a consultant to create a quality assurance program using Joint Commission standards, yet the only guideline for psychiatric care is the ambiguous term "appropriate." This lack of specificity indicates that prison officials never consented to judicial review of their psychiatric evaluation and treatment levels.
The case parallels Balla v. Idaho State Bd. of Corrections, where a contempt finding was deemed inappropriate due to the vagueness of the court order, which required a "systematic" screening program and "sufficient" mental health professionals. Civil contempt requires a clear and definite court order; thus, the vague standards cited by prisoners in this case cannot support a contempt motion. Substituting vague terms does not remedy the lack of specificity. Although Gates v. Shinn established that "appropriate psychiatric treatment as medically indicated" could be sufficiently specific, it involved a situation where the treatment method was clearly inappropriate. Here, there is reasonable disagreement about whether the outpatient plan offered "appropriate psychiatric treatment," making the standard insufficiently specific for upholding the contempt order. Consequently, the contempt finding against the prison officials is vacated, and the district court's decision is reversed, as the consent decree fails to establish a clear mandate for psychiatric care.
The contempt citation against prison officials is vacated without addressing their due process argument. The court does not engage with questions regarding the Prison Reform Litigation Act or its impact on the existing decree. The decree mandates that defendants provide appropriate psychiatric care for inmates at CMF, including screening, evaluation, treatment, and staff requirements to ensure adequate psychiatric services. Specific deadlines for program implementation and reporting are established, with an emphasis on reducing isolation and ensuring access to care. The consent decree has led to extensive litigation, with prior court decisions emphasizing the necessity of "fair notice" regarding compliance obligations. The prison officials argue that while they were aware of the decree's requirements, they contest the appropriateness of those requirements rather than claiming ignorance of them.
The district judge determined that prison officials had consistently failed to meet deadlines but opted not to impose civil sanctions due to a lack of concrete action to compel compliance. Consequently, the judge did not hold these officials in contempt for past delays. However, he identified ongoing non-compliance related to the adequacy of the defendants' submissions and actions regarding the Outpatient Psychiatric Program (OPP). The magistrate had previously allowed the prison officials a final opportunity to submit a complete revised plan, which was deemed insufficient by the mediator's experts unless thirteen specific modifications were made.
The judge concluded that the prison officials were not providing appropriate evaluation and treatment for all inmates at CMF, thereby finding them in contempt of section V.F of the consent decree. The contempt order indicated multiple violations, including issues related to medication, monitoring, evaluations, and recordkeeping. Although the specifics of the contempt determination were not detailed, they included disagreements about clozapine, staffing, and treatment protocols.
Sections V.F.2 and V.F.3 of the consent decree outline required elements for providing appropriate psychiatric care, including adequate staffing, timely evaluations, appropriate treatment facilities, and proper monitoring of medications. While some specifics were not quantified by the term "appropriate," they did not form the basis of the contempt finding. The differing interpretations of what constituted "appropriate" care between the prison officials and the mediator's psychiatric experts led to the court siding with the mediator’s recommendations. The document notes that the use of case-specific abbreviations and terms may create confusion for readers unfamiliar with the case, hence the preference for descriptive terms.
