Opinion ID: 557986
Heading Depth: 2
Heading Rank: 2

Heading: Adequacy of Treatment.

Text: 38 The district court organized its adequacy-of-treatment findings along five separate strata. 6 In synthesizing the findings, we follow the same mode. 39 1. Education; Special Needs. The reading proficiency of 75% of the patient population is below the eighth grade level; only 67 patients (less than 25% of the population) have high school diplomas or the equivalent. Beginning in August 1986, the Treatment Center budgeted for an instructor to lead a special education curriculum. Despite the obvious need for such a program, the position went unfilled for at least a year. In August 1987, Tink, the administrator of the Treatment Center, felt compelled to write to DMH's Assistant Commissioner seeking additional funding to enable the Center to fill staff vacancies in educational, and other, programs. 40 Recognizing this slow start, the court nonetheless found that defendants were on their way toward implementing a comprehensive educational system. At time of trial, a learning center was up and running and a specialized treatment program was in place for patients with modest intellectual skills. As of mid-March 1989, 102 patients were participating in various special needs/educational programs. Over half of them were enrolled in two or more courses; 34 were receiving classroom instruction for five periods a day, five days a week. 41 Educational opportunities were also being provided on a more generalized plane. Above and beyond those involved in special needs programming, 105 patients were partaking of other educational endeavors. Thirty-one were attending college-level courses taught by visiting faculty from Massasoit Community College and Bridgewater State College. Twelve were enrolled in a special computer course. Six were taking high school equivalency (G.E.D.) courses (an enrollment which, at trial, defendants acknowledged could, and should, be expanded). Classes were also offered in bibliognostic skills, graphic arts, crafts, and other disciplines. 42 The Treatment Center library, headed by a certified librarian, was fully operational, containing over 12,000 permanent volumes. The inventory included a current and comprehensive law library. Additional materials were available on revolving loan through a standing agreement with the Bridgewater Public Library. In the month prior to trial, a daily average of 89 patients visited the library; during that month, 233 different patients borrowed a total of 546 books. 43 In the last analysis, the court, although concerned about staffing shortages and the tiny enrollment in the G.E.D./pre-G.E.D. courses, found the overall improvement in the quantity, quality, and availability of educational programs to be impressive. 44 2. Vocational and Avocational Programs. The Treatment Center's vocational and avocational workshops also moved with near glacial slowness after construction was completed. While an avocational/occupational therapy (AVO/OT) area was built as part of the new complex, it remained largely unused for three years due to insufficient staffing. Tink, in his 1987 letter to DMH, wrote that my vocational training component really includes only two [full-time equivalent staff members].... Particularly because of inadequate staffing, I continue to be unable to open the AVO/OT program areas.... 45 The glacier did not really begin to thaw for over two years. By March 1989, 195 patients had enlisted in vocational or avocational programs. Various levels of permanent work status were available. A large majority of the participating patients were usefully involved in the construction of greenhouses at the Bridgewater State Hospital. The Treatment Center itself was a further source of employment for kitchen and canteen workers, clerical help, library aides, tutors, and graphic arts assistants. The Brockton Area Private Industry Council was providing career counselling. Nine patients were participating in a work-release program, leaving each day to work at local jobs and returning each evening. The Center also started an avocational workshop, targeted to serve 50 patients. Staffing shortages impeded full implementation of the program; at time of trial, only eight persons were enrolled. 46 Notwithstanding the three year delay in opening the AVO/OT area, the court found recent progress encouraging. It viewed staffing difficulties as the largest obstacle to complete implementation of the occupational and avocational programs and instructed the defendants to continue to employ their best efforts to fund and fill positions which have been allocated for these programs. 47 3. Recreation. A large gymnasium was built as part of the new complex. It enabled the recreation program to be overhauled and rejuvenated. The gymnasium is equipped with basketball courts, a weightlifting area, pool tables, and other accoutrements. As late as 1988, due to security and staffing problems, the facility was only open on a limited basis. By 1989, however, the gym was accessible seven days a week and offered a wide range of activities. During February 1989, 146 patients per day, on average, used the facility. 48 The Treatment Center also sports an excellent outdoor recreation area, including a baseball diamond and track. Sedentary forms of recreation, such as board games, are available in the common areas adjacent to each housing unit. A Recreation Advisory Board, composed of patients, has been established to offer suggestions regarding development and administration of additional recreational programs. 49 It seems clear that, by 1989, the patients' recreational needs were being more than adequately met. The district court, in effect, so found. 50 4. Therapeutic Programs. Under the new regime, sophisticated intake forms were devised and used. Shortly after a patient's admission, a review board conducts a formal assessment of his background and needs. This assessment ranges from general educational and behavioral evaluations to diagnoses of specific problem areas. The assessment is performed by the Treatment Center's research department, which has a national reputation for excellence. Following completion of the assessment, a treatment protocol is implemented. Monthly progress reports are generated as to all patients and a patient services information summary is compiled, showing, inter alia, patient utilization of various therapy and other services within the institution as a whole. 51 Most often, treatment is administered in the form of group therapy. Nevertheless, at time of trial, 45 patients were receiving some kind of individualized treatment. Therapeutic modalities ranged from housing unit meetings (HUMs) to specialized programs focusing on particular deficiencies, e.g., substance abuse, anxiety management, impulse control. 52 Once the new complex was completed in 1986, management made a reasoned professional decision that many of the one-on-one programs, i.e., those involving individual audiences between patient and clinician, were ineffective. It was decided to transform most of these programs into group sessions. According to the district court, this alteration in format, together with the concomitant shift from a psychodynamic treatment model to a behavioral/rehabilitative model, caused some upheaval. A significant number of unhappy clinical staffers departed between 1986 and 1989. 53 By the time of trial, most of the turmoil had subsided. Under the aegis of Dr. Jurgela, the new Clinical Director, and Mr. Cardoza, the new Director of Rehabilitation Services, the defendants were on the way toward establishing a comprehensive treatment program, emphasizing a cognitive behavioral approach. Each patient's specialized needs and treatment protocol were systematically outlined in an individualized treatment plan (ITP) issued by the RIRB. In one form or another, group therapy was being offered to every patient. HUMs were universally available and 213 patients were participating in them. These sessions allowed patients to ventilate and resolve their complaints against their fellow residents. Dr. Jurgela believed that the patients' recalcitrance skewed the statistics somewhat. He testified without contradiction that many of the patients were not desirous of receiving any treatment. 7 54 Withal, the trial court found that the defendants are often unable to provide all of the care specified by a patient's ITP: 55 Unfortunately, the treatment program outlined in a patient's ITP often bears little relation to the treatment the patient can actually expect to receive. This failure occurs in part because treatments are sometimes recommended even though they are not offered at the Treatment Center, and [sometimes] because the limited clinical staff at the Treatment Center is overburdened and unable to provide all of the recommended treatment. In fact, the RIRB itself has been unable to fulfill completely its mandate. As many as forty-five patients have not had their ITP's reviewed during the past twelve months.... 56 The defendants argued below that, notwithstanding this shortfall, significant progress had been made, particularly during the year preceding trial, toward implementing a comprehensive treatment system. Programs such as anger management, anxiety management, self control therapy, and relaxation therapy had been instituted. 8 Despite the recent increase in program availability, however, the very programs which related most directly to patients' sexual dangerousness, e.g., impulse control and systematic desensitization, were in the shortest supply. 9 57 The court observed that staff shortages posed the largest obstacle to full implementation of therapeutic services. 10 Moreover, staff shortages seemed to be worsening; in 1987, the Treatment Center was authorized to employ a crew of 72 and fielded 53, whereas two years later, it had 78 authorized positions, only 40 of which were filled. The court found these shortages, by and large, to be beyond the defendants' reasonable control; the location of the facility, anxiety over its future, and the violent nature of the population served to dissuade many potential applicants from accepting positions there. 58 On balance, the court concluded that the range of treatments presently offered satisfied the requirements of the consent decrees, reasoning that the defendants were not obligated to provide every conceivable kind of treatment that might have a beneficial effect. This conclusion stands in bold relief against the backdrop of a record which contains no colorable evidence that the Treatment Center was failing to treat any patients who desired to participate in treatment programs. 59 5. The Authorized Absence Program. The Authorized Absence Program (AAP), conceived by Judge Garrity in 1978, allows patients to live in the outside community on a limited basis. AAP participants are accorded varying degrees of freedom and supervision based on their clinical needs and the administration's assessment of security risks. Soon after taking office in 1985, Tink began working to eliminate a huge backlog in the processing of AAP applications. He also secured additional AAP staff positions, at higher salaries, in order to improve the quantity and quality of available staffing. By early 1989, 49 patients were enrolled. 60 The district court found that the defendants devoted great effort to ensuring that the AAP ran efficiently and effectively; that Tink was personally committed to the program's success; and that satisfactory progress had been made in this area. The court explicitly rejected plaintiffs' contention that Tink was not qualified to make final decisions regarding program participation. 61