Court Opinion

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Source: CourtListenerOpinion
Date Created: 2010-04-26 08:10:51+00
Date Added: 2024-06-11T08:50:58.202079
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PUBLISH

               IN THE UNITED STATES COURT OF APPEALS

                        FOR THE ELEVENTH CIRCUIT
                                                                    FILED
                         ________________________ U.S. COURT OF APPEALS
                                                            ELEVENTH CIRCUIT
                                                                03/19/99
                                 No. 98-8265                 THOMAS K. KAHN
                          ________________________               CLERK

                     D. C. Docket No. 5:94-CV-345-3(CWH)

KIMBERLY CAMPBELL,
                                                                  Plaintiff-Appellant,

                                      versus

JAMES SIKES, et al.,
                                                            Defendants-Appellees.

                          ________________________

                   Appeal from the United States District Court
                       for the Middle District of Georgia
                        _________________________
                               (March 19, 1999)

Before COX, CARNES and HULL, Circuit Judges.

HULL, Circuit Judge:

      Plaintiff-Appellant Kimberly Campbell appeals the magistrate judge’s grant of

summary judgment for Defendants on her medical-treatment and excessive-force

claims under 42 U.S.C. § 1983. After review, we affirm.

                                         1
                                          I. FACTS1

      On May 28, 1991, Plaintiff-Appellant Kimberly Campbell was transferred to the

Georgia Women’s Correctional Institution (“GWCI”) to serve five years of a ten-year

sentence for distribution of cocaine and interference with government property.

Plaintiff’s constitutional claims arise from the medical treatment she received at the

GWCI state prison between May 28, 1991, and January 30, 1992.

A.    Mental Health Treatment

      The day Plaintiff arrived at GWCI, she was seen by physician Grant Carmichael,

who noted that Plaintiff had a history of suicidal threats and had taken psychotropic

drugs previously at the Cobb County jail. Carmichael referred Plaintiff to the mental

health staff for a mental status exam.

      That same day, Plaintiff met with mental health counselor Anne Weathers for

a mental status exam. Weathers obtained from Plaintiff extensive details about her

psychiatric history, including prior medications, hospitalizations, treatments, and

symptoms, and she prepared a three-page report summarizing her observations and

findings.

       1
         The magistrate judge devoted 43 pages of a 102-page order to giving a detailed
summary of Plaintiff’s treatment at GWCI. Rather than reiterating the same details, we give
only an overview of the facts, highlighting a few representative occurrences of Plaintiff’s self-
destructive behavior and Defendants’ various responses.

                                                2
                                                2
      Weathers’s report first details Plaintiff’s own descriptions of her history of

alcohol and drug use. Plaintiff admitted using drugs on and off since age thirteen and

drinking excessively–as much as a half pint of liquor a day and a quart of beer a day.

The report indicates that Plaintiff used marijuana at first, then beer, Valium, and

ultimately “cocaine/crack.”

      Weathers’s report then focuses on Plaintiff’s psychiatric history. Plaintiff told

Weathers that while in school, she received mental health services for “problems with

nerves” but no medications. Plaintiff also reported having a “nervous breakdown” at

age eighteen, being hospitalized for a month and a half, receiving Valium, and having

a seizure. After release from the hospital, Plaintiff received services in a day hospital

for several months. She continued to have problems with nerves and panic attacks, and

she got Darvon and Valium from friends to help her cope with these problems.

Plaintiff related two suicidal incidents to Weathers: at age nineteen, Plaintiff cut her

wrist superficially, and at age twenty-two, she took an overdose of lithium in the

presence of her husband’s son.2

       2
         In the district court, Plaintiff introduced medical records showing that between 1982
and 1988, she had been hospitalized thirteen different times seeking treatment for depression,
mood swings, suicide attempts, anxiety, paranoia, sleep disturbances, and substance abuse.
Although these records show Plaintiff was treated with various medications, including Stelazine
and lithium, they show no diagnosis of bipolar disorder–the diagnosis Plaintiff contends
Defendants should have made.

                                               3
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       Weathers’s report next turns to Plaintiff’s treatment at the Cobb County jail after

she was arrested on the cocaine offense. Plaintiff told Weathers that while in the jail,

she became anxious, was panicky, heard loud bells ringing in her head, began to sweat,

and felt claustrophobic. Plaintiff reported that she was seen by a psychologist and

received lithium, Stelazine, Mellaril and Benadryl. According to Plaintiff’s account,

she received mental health care in the jail because she told jail officials she was

thinking of harming herself. Plaintiff reported that the last four days at the jail, she had

not received any medications.

       Weathers’s report states that she contacted the Cobb County jail and confirmed

that Plaintiff had received the above medications at the jail and that when she left their

facility she was taking Trilafon. The jail also advised that Plaintiff was intoxicated

upon admission to the jail, was unstable and began taking off her clothes, and made

statements about self injury. The jail placed her on suicidal precaution. Weathers’s

report relates that the jail officials believed Plaintiff’s suicide threats were a

“manipulative ploy” because the jail was reducing her medication:

       They said that off and on throughout the stay that she did make
       statements about intent to harm herself, but that it was noted that it
       appeared to be a manipulative ploy in that they were reducing her
       medication to stabilize her. They did not consider that she was making
       a serious suicide threat; however, they did place her on suicide watch on
       several occasions as a precaution.

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      Weathers’s report also contains Weathers’s own observations from interviewing

Plaintiff. According to the report, Plaintiff’s memory was intact for recent and remote

events, and there was no evidence Plaintiff was responding to hallucinations. While

denying “delusions and grandiose ideation,” Plaintiff reported being anxious, described

a fear of being out of control, and requested to see a doctor to be placed on medication

“to help her rest.” Weathers’s report concludes with the following recommendation

that Plaintiff be seen by a psychiatrist:

      Ms. Campbell reports a history of panic attacks and anxiety related
      symptoms. She also gives a history of suicidal thoughts and manipulative
      suicidal acts. At the present time, she denies intent to harm herself and
      signs of anxiety. As she was taking medication while in the Cobb County
      jail it is recommended that she be seen by Dr. Sikes to evaluate the need
      for continuing medication and to make recommendation for treatment.

      Dr. James Sikes, a psychiatrist, met with Plaintiff on June 3, 1991. Before the

meeting, he reviewed Weathers’s report, which he noted specified that Plaintiff had

been prescribed psychotropic drugs lithium and Trilafon at the Cobb County jail. Sikes

noted, too, that Plaintiff had related a long history of intravenous use of cocaine as well

as heavy alcohol consumption. His report states that the intermittent anxiety and

psychiatric hospitalizations in Weathers’s report appeared to arise from complications

with drugs and medication. Moreover, Sikes noted that Plaintiff denied having any

schizophrenic episodes, auditory hallucinations, or delusional thoughts.

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                                            5
      At the meeting with Plaintiff, Sikes observed Plaintiff’s current condition. He

found her to be calm and cooperative. He saw no evidence of delusional thought or

loosening of associations. After meeting with Plaintiff and reviewing Weathers’s

report, Sikes directed that Plaintiff’s Trilafon be discontinued.

      Sikes scheduled a follow-up session with Plaintiff for July 1 in order to observe

her behavior once she had been off Trilafon for a few weeks. Sikes’s report from that

meeting notes the absence of any reported problems up to that point. The report also

states that at the interview, Plaintiff told Sikes she had experienced trouble sleeping

and “what she consider[ed] as normal adjustment to the prison.” Sikes suggested

increased activity but reported “no evidence of a schizophrenic illness.”

      Sikes met with Campbell again on August 12. His reports from that meeting

indicate he diagnosed Plaintiff as suffering from polysubstance abuse arising from her

prior alcohol and drug abuse. Sikes also noted that Plaintiff was “angry and resentful

of being called up to talk about things” and that she would probably “continue to clash

with authoritative figures.” His thoughts on Plaintiff’s condition remained unchanged:

“I see no indication of schizophrenia or Bipolar Disorder and will continue to see her

as needed should further concerns occur.” Sikes found no indications of schizophrenia

(a thought disorder) or bipolar disorder (a mood disorder) because Plaintiff showed “no

looseness of associations, no evidence of delusional thought”; he explained, “this

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seems to be a failure to adjust to the conditions of incarceration rather than a presence

of a psychiatric illness.” Sikes concluded that psychotropic medication should not be

prescribed absent a diagnosis of mental illness. According to Sikes’s reports, he did

not prescribe psychotropic medication because he diagnosed Plaintiff as suffering from

polysubstance abuse and not a mental illness.

      Sikes and other mental health professionals met with Plaintiff numerous times

in the months ahead. Sikes himself saw Plaintiff sixteen times: June 3, July 1, August

12, September 4 or 6, 18, 20, 23, 25, and 30, October 9 and 25, November 1, 8, and 25,

December 6, and January 29. In mid-September, when Plaintiff’s behavior began to

deteriorate, Sikes reported, “It appears that this woman ‘acts strangely’ to get attention

or perhaps to earn additional privileges or perhaps to avoid prosecution for her various

disciplinaries.” He recommended establishment and enforcement of clear rules in

order to aid Plaintiff in learning to respect and obey authority. Sikes was confident of

Plaintiff’s capability to conform her behavior to institutional rules. He thus explained,

“She has a temper as many inmates do but she should be held accountable for whatever

rules she breaks.” During each meeting with Plaintiff, Sikes continued to find no

evidence of a psychiatric illness justifying treatment with medication.

      Other members of the mental health staff also met with Campbell and reached

similar conclusions. Plaintiff was placed on the caseload of mental health counselor

                                            7
                                            7
Valarie Ford. Ford met with Plaintiff thirty-four times between August 1991 and

January 1992: August 1, September 16, 17, 19, 20, 23, 24, 26, and 27, October 10, 14,

15, 16, 21, 22, 23, 24, 25, 27, 28, and 29, November 4, 6, 13, and 19, December 4, 5,

6, 7, 8, 10, 11, and 18, and January 14. Ford reports that she also saw Campbell

informally almost every day during that time period. According to Ford, from the time

of the first meeting she perceived Campbell’s behavior as manipulative and saw no

evidence of psychosis.

       After her first meeting with Plaintiff, Ford referred Plaintiff to Psychologist Dr.

Archer Moore, who also met with Plaintiff on August 1. Moore’s report from that

meeting states Plaintiff was “a very angry young woman who denie[d] any thought of

hurting herself.” Moore found “good reality contact” but “strong narcissistic features.”

During Plaintiff’s stay at GWCI, Moore saw her six times total, (August 1, September

5, 19, 26, and October 10 and 14), and he believed she suffered from a “Narcissistic

Personality Disorder” and not a mental illness but stressed that he considered Plaintiff

to be primarily Sikes’s patient.

       No one on the GWCI staff ever diagnosed Plaintiff as suffering from bipolar

disorder or prescribed psychotropic medications. Instead, the GWCI staff attributed

Plaintiff’s behavior to the lingering effects of her prior substance abuse, the difficulties

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of adjusting to life in prison, and, on some occasions, deliberate attempts to manipulate

officials.

B.     Restraints

       During June, July, and August 1991, Plaintiff was sanctioned a few times for

minor disciplinary infractions. In September 1991, however, Plaintiff began engaging

in defiant behavior that eventually became violent, self-destructive, and even suicidal.

On several occasions, she thrashed about her cell, climbed up on the sink, ripped her

sheets to shreds, beat on and dismantled the overhead light, and attempted to obtain

sharp objects. Plaintiff also bit and scratched prison officials and threatened to “hurt

someone.” Plaintiff often threatened to flood the toilet, which posed a security risk

because it could mandate evacuation of other cells in the unit. In addition, Plaintiff

started multiple fires in her cell, burning her food tray, her Bible, her clothing, and

other such items. One clothing fire she started caused her entire cellblock to be

evacuated.

       Prison officials responded by removing potentially harmful belongings,

instituting terms of solitary confinement, and restraining Plaintiff using several forms

of restraint.   Officials gradually increased the level of restraint.        They used

straightjackets on several occasions, which made Plaintiff’s hands unusable but left her

able to walk around the cell. On at least one occasion when officials used only a

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straightjacket, Plaintiff began banging her head and kicking. When Plaintiff’s behavior

escalated, officials also used “four-point restraints” at least five times, anchoring each

of her arms and legs to a different point on the bed.

      Throughout her stay at GWCI, Plaintiff demonstrated an uncanny ability to

escape from most forms of restraint. She removed her straightjacket on numerous

occasions, and at least once, she freed herself from four-point restraints.

      Plaintiff’s complaint, however, focuses mainly on the instances in which

officials employed a third method of restraint that left her in an “L” shape3 with her

knees bent so that her calves were perpendicular to her back. To use this form of

restraint, officials first immobilized Plaintiff’s hands and arms using either a

straightjacket or handcuffs behind her back. Next, they put handcuffs on her ankles.

Finally, they used a strap that ran the length from the handcuffs on her ankles up to the

handcuffs on her wrists. This left Plaintiff in an “L” shape, with her body from her

head to her knees defining the vertical part of the “L” and the lower portion of her

legs–from her knees along her calves to her feet–defining the horizontal portion of the

“L.” This “L” shape restraint would have resulted in Plaintiff’s being in a kneeling

position had she been left upright. Most of the time, she was lying on her side with the

       3
        Plaintiff calls it “hog-tying,” and Defendants call it “tethering.” We refer to it as the
“L” shape method of restraint.
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                                                10
“L” shape on a plane parallel to the ground. On at least one occasion, Plaintiff freed

herself from the leg tether while this “L” shape form of restraint was being used.

      Although Plaintiff entered GWCI in May 1991, Sikes first ordered Plaintiff

restrained using this “L” shape method on September 18, 1991. On September 17,

Plaintiff was observed standing on the bed with a sheet wrapped around the back of her

neck. Believing Plaintiff might be trying to commit suicide, mental health staff

removed her clothing and other belongings, placed her in seclusion, conducted security

checks every fifteen minutes, and monitored her condition using a camera.

      The next morning, Plaintiff was sent to Sikes for evaluation. She yelled at Sikes,

turned over a table, and broke a phone. When Plaintiff was returned to seclusion and

ordered to strip in front of male guards, she refused. Upon a second request, she

complied but began running around the cell, kicking and butting the wall. Officials

then contacted Sikes, who ordered Plaintiff placed in a straightjacket, which

immobilized her hands and arms. Shortly thereafter, Plaintiff began banging her head

and kicking. When informed of this behavior, Sikes ordered that Plaintiff be placed

in a helmet and that the “L” shape restraint be employed. This immobilized her legs

as well as her arms, preventing her from jumping, climbing, kicking, and running

around the cell.

                                          11
                                          11
      Between September 18 and October 28, officials restrained Plaintiff using this

“L” shape method five times.4 In addition to the twenty-seven hours on September 18

to 19, the “L” shape restraints were applied for about one hour and twenty-five minutes

on September 22, five hours on October 12 to 13, sixteen hours on October 23 to 24,

and sixty-six hours and forty minutes on October 25 to 28.5

      Although the restraints undoubtedly caused physical discomfort and emotional

pain, they undisputedly caused Plaintiff no physical injury. It is also undisputed that

officials monitored Plaintiff’s physical condition while she was restrained. Plaintiff’s

circulation was checked each time the “L” shape method of restraint was applied, and

security officers checked her every fifteen minutes while she was restrained. Medical

staff also provided regular checks; a nurse assessed Plaintiff’s condition every few

hours, and a doctor reevaluated the need for restraints every twenty-four hours.

       4
         Plaintiff actually alleges “at least five times.” Undisputed facts include five clear
instances of the “L” shape restraint and other times when the exact type of restraint used is
unclear.
       5
          Although we describe only the first use of the “L”shape restraint, the magistrate judge’s
order details all five occurrences and Plaintiff’s violent and often self-destructive behavior
precipitating the use of the “L” shape restraint. The approximate periods of the “L” shape
restraint are (1) from 10:05 a.m. on September 18 to 1:05 p.m. on September 19; (2) from 10:20
p.m. to 11:45 p.m. on September 22; (3) from 9:45 p.m. on October 12 to 2:45 a.m. on October
13; (4) from 10:05 p.m. on October 23 to 2:15 p.m. on October 24; (5) from 3:30 p.m. on
October 25 to 10:10 a.m. on October 28.

         During these periods of restraint, Campbell was reevaluated every twenty-four hours and
left in restraints only if her self-injurious inclinations were still apparent. For example, restraints
were continued during the longest (almost 67-hour) period of restraint because Campbell
threatened to drink Clorox if the restraints were removed.
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                                                 12
      On at least two occasions, Defendant Sikes declined to approve restraints

requested by other officials. Plaintiff admits that on each of these occasions, Sikes

explained to the requesting officers that restraints were inappropriate when Plaintiff did

not pose an immediate threat to her own safety.

      Although used five times between September 19 and October 28, the “L” shape

restraints were not used during November and December 1991 or January 1992.

Plaintiff asserts the “L” shape restraints were discontinued because a prison deputy

commissioner had issued an edict proscribing “hogtying.”

C.    Outside Evaluations

      In December 1991, Plaintiff requested to be taken off the mental health caseload.

The staff conferred and determined that Plaintiff did not have an Axis I diagnosis and

that she would still have a counselor and access to mental health services as needed in

the general population. Thus, they granted her request and reassigned her to the

general population on December 31.

      On January 28, 1992, Plaintiff was placed in four-point restraints for setting four

fires and breaking the lights in her cell. On January 29, Plaintiff wrapped torn strips

from her jumpsuit around her neck in an attempted suicide. The next day officials sent

her to a forensic mental health unit at Central State Hospital for additional psychiatric

                                           13
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evaluation. Doctors there diagnosed Plaintiff as suffering from bipolar disorder and

prescribed the psychotropic medications lithium and Mellaril.

      Plaintiff was returned to GWCI for the remainder of her incarceration. Because

Sikes was no longer working at GWCI, Plaintiff was evaluated by Dr. Richard Panico,

who had just begun working as a part-time consulting psychiatrist at GWCI. Dr.

Panico diagnosed Plaintiff as suffering from bipolar disorder and prescribed lithium.

      Plaintiff was paroled in March 1993. After her release, Plaintiff was admitted

to Georgia Regional Hospital in February 1994. The Georgia Regional Hospital

records indicate that the February admission was due to “a serious overdose on

lithium” and that Plaintiff had “a past history of suicidal threats.”

      Plaintiff was admitted again to Georgia Regional Hospital for reevaluation and

treatment on April 28, 1994. At this admission, psychological testing was done to aid

in evaluating Plaintiff. The Georgia Regional Hospital records reveal that Plaintiff was

diagnosed as presenting a “personality disorder,” “with borderline anti-social features,

and an Axis I diagnosis of alcohol and substance abuse.” At Georgia Regional

Hospital, the treating psychiatrist specifically noted that “Plaintiff did not present an

Axis I diagnosis of bipolar disorder.”

                           II. PROCEDURAL HISTORY

A.    Complaint

                                           14
                                           14
      Plaintiff filed a complaint in state court in nine counts: (1) a § 1983 claim for

deliberate indifference to serious medical needs; (2) a § 1983 claim for cruel and

unusual punishment through use of stripping, restraint, and isolation; (3) a § 1983

claim for excessive force; (4) a § 1983 substantive-due-process claim for punishment

in lieu of treatment; (5) a § 1983 claim alleging infringements of Plaintiff’s procedural-

due-process and First Amendment rights; (6) a claim under the Georgia Tort Claims

Act (“GTCA”) for medical and professional negligence; (7) a GTCA claim for

intentional infliction of emotional distress; (8) a GTCA claim for neligence and

intentional infliction of emotional distress against Sikes and Moore as independent

contractors; and (9) a claim alleging violations of the Georgia Constitution and a

Georgia statute regarding types of punishment. The five defendants in Plaintiff’s

initial complaint were the Georgia Department of Corrections (“GDOC”), Mental

Health Director Albert Duncan, Psychiatrist James Sikes, Psychologist Archer Moore,

and Warden Art Gavin.

      Defendants removed to federal court in the Northern District of Georgia. In

federal court, Plaintiff filed her first amended complaint, which incorporates the claims

in the initial complaint and adds Mental Health Counselor Valarie Ford as a Defendant.

The district court granted Plaintiff’s motion to amend.

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      The district court also granted in part Plaintiff’s motion to remand to state court,

remanding all claims against the GDOC and any official-capacity claims against

Duncan, Sikes, Moore, Gavin, and Ford. Thus, remaining in federal court were

Plaintiff’s individual-capacity claims against Duncan, Sikes, Moore, Gavin, and Ford.

B.    Motions for Summary Judgment

      After Defendants’ motion for a transfer to the federal court in the Middle District

of Georgia was granted, the parties consented to proceeding before a magistrate judge

and began discovery. Defendants filed separate motions for summary judgment,

arguing Plaintiff had failed to allege a constitutional violation and asserting qualified

immunity.

C.    Magistrate Judge’s Order

      On January 28, 1998, the magistrate judge issued an order (1) granting

Defendants Sikes, Moore, Gavin, and Ford summary judgment based on qualified

immunity on all five of Plaintiff’s § 1983 claims; (2) granting those Defendants

summary judgment on any Georgia Tort Claims Act claims still in federal court; and

(3) with Plaintiff’s consent, dismissing Duncan as an improper party.

D.    Scope of This Appeal

      Plaintiff’s appeal challenges only the magistrate judge’s grant of summary

judgment on her § 1983 claims against Defendants Sikes, Moore, Gavin, and Ford.

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Plaintiff does not appeal the dismissal of Defendant Duncan or the grant of summary

judgment for Defendants on any Georgia Tort Claims Act claims remaining in federal

court. Plaintiff also abandons certain constitutional violations alleged in her first

amended complaint. She primarily focuses on two distinct alleged violations of the

Eighth Amendment: (1) Defendants’ deliberate indifference to serious medical needs,

and (2) Defendants’ excessive force.

      Thus, on appeal, we discuss whether the magistrate judge erred in granting

summary judgment for Defendants Sikes, Moore, Gavin, and Ford on Plaintiff’s §

1983 claims for deliberate indifference to serious medical needs and for use of

excessive force.6

    III. REVIEW OF SUMMARY JUDGMENT BASED ON QUALIFIED
                         IMMUNITY

      We review the magistrate judge's grant of summary judgment de novo. Steele

v. Shah, 87 F.3d 1266, 1269 (11th Cir. 1996). In doing so, we “evaluate the summary

judgment record in the light most favorable to . . . the nonmovant,” and we will affirm

the district court’s grant of summary judgment only if the record demonstrates that

there was no genuine issue of material fact and that Defendants were entitled to

judgment as a matter of law. Id.; Fed. R. Civ. P. 56.

       6
         To the extent that Plaintiff appeals other claims and issues, we find no reversible error
in the decision of the magistrate judge. See 11th Cir. Rule 36-1.

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      The magistrate judge’s order and the parties’ briefs focus almost exclusively on

qualified immunity and the question of whether, at the time of Defendants’ actions, the

law clearly established that Plaintiff’s rights were being violated. We turn first to an

alternate basis for summary judgment, inquiring whether this record contains any

evidence of an underlying constitutional violation. Because Plaintiff’s evidence would

not support a reasonable jury’s finding that Defendants violated Plaintiff’s

constitutional rights, we need not address the applicability of qualified immunity. See

Killian v. Holt, — F.3d —, No. 97-6802 (11th Cir. Feb. 4, 1999) (affirming district

court's entry of summary judgment for defendants without qualified immunity analysis

because plaintiff “failed to bring forth evidence from which reasonable jurors could

find that defendant prison officials knew of and were deliberately indifferent to a

substantial risk of serious harm”); Hale v. Tallapoosa County, 50 F.3d 1579, 1582

(11th Cir. 1995) (affirming summary judgment for one defendant without relying on

qualified immunity because the plaintiff’s evidence was “insufficient to support the

level of deliberate indifference and causal connection necessary”);7 see also Cottrell

v. Caldwell, 85 F.3d 1480, 1489-92 (11th Cir. 1996) (in an interlocutory appeal of the

district court’s denial of summary judgment, turning first to plaintiff’s evidence of the

       7
         See also Crawford-El v. Britton, 118 S. Ct. 1584, 1586 (noting that when a claim
requires “proof of wrongful motive,” it may be preferable to begin summary judgment analysis
by examining the proof of intent because “the immunity question . . . sometimes requires
complicated analysis of legal issues”).

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constitutional violation itself and holding, “plaintiff has failed to show a violation of

due process, and it necessarily follows that the defendants are entitled to summary

judgment on qualified immunity grounds”); Adams v. Poag, 61 F.3d 1537 (11th Cir.

1995) (in another interlocutory appeal of a district court’s denial of summary

judgment, holding defendants were entitled to summary judgment based on qualified

immunity because plaintiffs had failed to present evidence of deliberate indifference

to support their Eighth Amendment claim).8

                              IV. EIGHTH AMENDMENT

      The Eighth Amendment governs the conditions under which convicted prisoners

are confined and the treatment they receive while in prison. Farmer v. Brennan, 511

U.S. 825, 832 (1994) (quoting Helling v. McKinney, 509 U.S. 25, 31 (1993)); see also

Whitley v. Albers, 475 U.S. 312, 327 (1986) (holding that “the Due Process Clause

affords . . . no greater protection”). Although the Constitution does not require

comfortable prisons, it does not permit inhumane ones. Farmer, 511 U.S. at 832

       8
         We observe that this case–unlike Cottrell and Adams–is an appeal from a final
judgment, where there is no dispute that we can examine first whether there is sufficient
evidence to support a reasonable jury’s finding a constitutional violation. However, Cottrell and
Adams show that even in interlocutory appeals limited strictly to qualified immunity issues, the
same procedure is permissible. In another qualified immunity interlocutory appeal, Dolihite v.
Maughon, 74 F.3d 1027 (11th Cir.) cert. denied, 117 S. Ct. 185 (1996), this Court again focused
on the “predicate element of the underlying constitutional tort,” which is “part and parcel of the
core qualified immunity issue which is immediately appealable.” Id. at 1033 n.3. Even if
identification of the precise knowledge of each defendant is not “part and parcel of the core
qualified immunity issue,” it is “‘inextricably intertwined’ with the core issue and thus would be
immediately appealable.” Id.

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(quoting Rhodes v. Chapman, 452 U.S. 337, 349 (1981)). Still, the Eighth Amendment

does not authorize judicial reconsideration of “every governmental action affecting the

interests or well-being of a prisoner,” Whitley, 475 U.S. at 319; instead, “‘[a]fter

incarceration, only the “‘unnecessary and wanton infliction of pain’”. . . constitutes

cruel and unusual punishment forbidden by the Eighth Amendment.’” Id. at 319

(quoting Ingraham v. Wright, 430 U.S. 651, 670 (1977) (quoting Estelle v. Gamble,

429 U.S. 97, 103 (1976) (citations omitted))).

       Crucial to establishing an “unnecessary and wanton infliction of pain” is some

proof that officials acted with specific intent. This specific-intent requirement for an

Eighth Amendment violation applies to both failure to provide proper medical care,

Steele v. Shah, 87 F.3d 1266, 1269 (11th Cir. 1996), and excessive force, see Whitley,

475 U.S. at 319-21. However, the exact nature of the specific intent required depends

on the type of claim at issue. Whitley, 475 U.S. at 319. Thus, we address each claim

in turn.

   V. “DELIBERATE INDIFFERENCE” TO SERIOUS MEDICAL NEEDS

       The Eighth Amendment’s proscription of cruel and unusual punishments

prohibits prison officials from exhibiting deliberate indifference to prisoners’ serious

medical needs. Estelle v. Gamble, 429 U.S. 97, 104 (1976). The Supreme Court has

been careful to note, however, that “a complaint that a physician has been negligent in

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diagnosing or treating a medical condition does not state a valid claim of medical

mistreatment under the Eighth Amendment.” Id. at 106. Thus, in Estelle v. Gamble,

which first enunciated the “deliberate indifference” standard, the Supreme Court

reinstated the district court’s dismissal of a prisoner’s § 1983 complaint for failure to

state a claim. Noting that the complaint’s primary allegation was that “more should

have been done” to diagnose and treat a back injury, the Court explained, “A medical

decision not to order an X-ray, or like measures, does not represent cruel and unusual

punishment. At most it is medical malpractice.” Id. at 107.

      Subsequent Supreme Court cases have refined the inquiry. In Wilson v. Seiter,

501 U.S. 294 (1991), the Supreme Court explained that the Eighth Amendment applies

only to punishments and that prison conditions are only punishment if a mental element

of punitive intent is shown:

      The source of the intent requirement is not the predilections of this Court,
      but the Eighth Amendment itself, which bans only cruel and unusual
      punishment. If the pain inflicted is not formally meted out as punishment
      by the statute or the sentencing judge, some mental element must be
      attributed to the inflicting officer before it can qualify.

Id. at 300. Although the very imposition of a certain term in prison is punitive, the

punitive purpose of the sentence itself does not convert every attribute of the place of

incarceration into a punishment subject to Eighth Amendment scrutiny. Thus,

conditions of confinement violate the Eighth Amendment only if they (1) rise to the

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level of a “serious” deprivation; and (2) result from the official’s “deliberate

indifference.” Id. at 297-99. Wilson and subsequent cases refer to these two required

elements as an “objective component” scrutinizing the alleged deprivation and a

“subjective component” examining the official’s mental intent.

A.    Farmer v. Brennan Requires Proof Of Subjective Mental Intent

      Most recently, in Farmer v. Brennan, 511 U.S. 825 (1994), the Supreme Court

explained further the requisite “subjective component” of a conditions-of-confinement

claim and defined the exact subjective mental state required for “deliberate

indifference,” as follows:

      [A] prison official cannot be found liable under the Eighth Amendment
      for denying an inmate humane conditions of confinement unless the
      official knows of and disregards an excessive risk to inmate health or
      safety; the official must both be aware of facts from which the inference
      could be drawn that a substantial risk of serious harm exists, and he must
      also draw the inference. This approach comports best with the text of the
      Amendment as our cases have interpreted it. The Eighth Amendment
      does not outlaw cruel and unusual "conditions"; it outlaws cruel and
      unusual "punishments." An act or omission unaccompanied by
      knowledge of a significant risk of harm might well be something society
      wishes to discourage, and if harm does result society might well wish to
      assure compensation. The common law reflects such concerns when it
      imposes tort liability on a purely objective basis. But an official's failure
      to alleviate a significant risk that he should have perceived but did not,
      while no cause for commendation, cannot under our cases be condemned
      as the infliction of punishment.

Id. at 837-38 (emphasis added) (internal citation omitted). Thus, in light of Farmer,

liability may be imposed for deliberate indifference only if the plaintiff proves the

                                           22
                                           22
defendant actually knew of “an excessive risk to inmate health or safety” and

disregarded that risk. Id. at 837. Proof that the defendant should have perceived the

risk, but did not, is insufficient. Id. at 838; Cottrell v. Caldwell, 85 F.3d 1480, 1491

(11th Cir. 1996) (“There is no liability for ‘an official’s failure to alleviate a significant

risk that he should have perceived but did not . . . .’” (quoting Farmer, 511 U.S. at

838)). Thus, the official must have a subjectively “‘sufficiently culpable state of

mind.’” Cottrell, 85 F.3d at 1491 (quoting Farmer, 511 U.S. at 834).                     This

“requirement follows from the principle that ‘only the unnecessary and wanton

infliction of pain implicates the Eighth Amendment.’” Farmer, 511 U.S. at 834

(quoting Wilson, 501 U.S. at 297).

B.     Post-Farmer Decisions

       This Court recently applied Farmer in the psychiatric medical needs context in

Steele v. Shah, 87 F.3d 1266 (11th Cir. 1996). In Steele, a Florida inmate claimed that

a prison psychiatrist was deliberately indifferent in discontinuing prescribed

psychotropic medication. The Steele Court explained that under Farmer, summary

judgment must be granted for the defendant official unless the plaintiff presents

evidence of the official’s subjective knowledge, as follows:

       since a finding of deliberate indifference requires a finding of the
       defendant's subjective awareness of the relevant risk, Farmer v. Brennan,
       511 U.S. 825, ----, 114 S. Ct. 1970, 1979, 128 L.Ed.2d 811 (1994), a
       genuine issue of material fact exists only if the record contains evidence,

                                             23
                                             23
      albeit circumstantial, Farmer, 511 U.S. at ----, 114 S. Ct. at 1981, of such
      subjective awareness. See Cottrell v. Caldwell, 85 F.3d 1480, 1491 (11th
      Cir.1996) (acknowledging Farmer's requirement of subjective awareness
      and rejection of a solely objective test of deliberate indifference).

Id. at 1269 (emphasis added).

      This subjective knowledge was evidenced in Steele by the underlying facts and

circumstances of the case. The plaintiff had been prescribed psychotropic medications

at a previous institution. Id. at 1267. When the plaintiff was transferred to a new

prison, the defendant, Dr. Shah, saw the plaintiff for “less than one minute” and

discontinued psychotropic medications. Id. Shah did not review any medical records

other than the Treatment Plan listing medications prescribed by the prior institution,

and he did not consult with any medical staff. Id. After Shah discontinued the

plaintiff’s medication, medical staff from the prior institution wrote the new prison

expressing concern that the plaintiff was a suicide risk, had been on psychotropic

medication, and was not now receiving his medication. Id. at 1268. Their letters

clarified that the plaintiff had been diagnosed as having “Adjustment Disorder with

Anxious Mood,” needed psychotropic medication, had tried suicide twice, and was

considered a suicide risk. Id. at 1267-68. Still, Shah did not respond; the plaintiff

continued without psychotropic medication for the duration of his time at the new

prison. Id.

                                          24
                                          24
        This Court held that a jury would be entitled to find that Shah had discontinued

the plaintiff’s medication “on the basis of one cursory interview and without having

reviewed any medical records beyond the Treatment Plan sent over from the Polk

facility.” Id. at 1270.   The Court continued that a jury could further find that Shah

“‘knew of a substantial risk from the very fact that the risk was obvious,’” that Shah

“deliberately disregarded that risk,” and that Shah “was aware from Polk personnel that

Steele was considered by them to be a potential suicide risk, and that that was one basis

for their prescription of the psychotropic drugs.” Id. (quoting Farmer, 511 U.S. at

842).

        The Steele Court noted that this circuit’s two most directly relevant precedents

both pre-dated Farmer. Id. at 1269 n.2 (citing Greason v. Kemp, 891 F.2d 829 (11th

Cir. 1990); Waldrop v. Evans, 871 F.2d 1030 (11th Cir. 1989)). However, the Steele

Court found that Farmer did not necessarily affect the holdings in those two pre-Farmer

cases, stating “Greason (surely) and Waldrop (almost as surely) based their specific

holdings on the existence of evidence of subjective awareness.” Id. We understand

Steele’s equivocation about Waldrop’s holding because Waldrop discusses only what

                                           25
                                           25
a reasonable person would have known–an objective test.9 However, we do examine

Greason in detail because Steele relies so heavily on Greason.10

      In Greason, the inmate’s prior therapist at Gwinnett County Mental Health

Center had sent a letter to the prison doctor describing the inmate’s current mental

status, relating his history of mental illness, and noting that he had been hospitalized

thirteen times and diagnosed as a “schizophrenic” with suicidal tendencies. Id. at 831-

32. The therapist urged continuation of the inmate’s medication for his diagnosed

mental illness and close monitoring. Id. The inmate’s psychiatrist at the Georgia

Department of Human Resources also sent a letter reporting that the inmate continued

       9
          Waldrop never addresses whether there is sufficient evidence for a reasonable jury to
find the defendants knew their case was grossly inadequate. Instead, Waldrop inquires whether
there is evidence that the defendants’ actions were grossly incompetent and violated professional
standards, and it focuses on what a reasonable person in the defendants’ position would have
known. Waldrop, 871 F.2d at1034-36. Thus, Steele was correct in hesitating to rely on
Waldrop’s assessment of the evidence now that Farmer has clarified the subjective-intent
requirement. Steele, 87 F.3d at 1269 n.2. Like the Steele Court, we focus instead on Greason.
       10
            We question Steele’s characterization of Greason as basing its holding on evidence of
subjective awareness. Greason is a pre-Farmer case that does not purport to apply the Farmer
subjective prong. Instead, Greason examines the evidence of deliberate indifference in the
context of an objective qualified immunity analysis. Although Greason does state, “we believe
that a trier of fact could find that Dr. Fodor provided such care [grossly inadequate psychiatric
care] and, moreover, that he realized that he was doing so at the time,” id. at 835, the ultimate
holding in Greason is that “a jury could find (1) that Dr. Fodor provided grossly inadequate care
and (2) that a reasonable person in Dr. Fodor’s position would have known that the care
delivered constituted deliberate indifference to Greason’s Eighth Amendment rights.” Id.
(emphasis supplied).
         Nonetheless, we are not required to resolve whether Steele correctly characterizes
Greason’s holding, the precedential effect of Steele’s statements about and reliance on pre-
Farmer Greason, or whether the facts of Greason would have met the Farmer test because, in any
event, Greason’s facts are readily distinguishable from those in this case.

                                              26
                                              26
to have suicidal thoughts and needed to be maintained on his medication. Id. at 832.

Both letter reports were in the inmate’s clinical file. Id.

      Two and a half months after the inmate’s arrival, the prison psychiatrist saw him

for a few minutes, promptly concluded that his condition had stabilized, and

discontinued his medications without reviewing the clinical file or assessing his mental

status to determine his potential for suicide. About a month later, the psychiatrist saw

the inmate again for only a few minutes.11 Based on these facts, the Greason Court

found that there was sufficient evidence from which a jury could conclude that the

psychiatrist provided grossly inadequate medical care “and, moreover, that he realized

that he was doing so at the time.” Id. at 835 (emphasis supplied).

      The parties also cite other post-Farmer Eleventh Circuit decisions involving

deliberate indifference to an arrestee’s or an inmate’s non-psychiatric medical needs.

See, e.g., Lancaster v. Monroe County, Ala., 116 F.3d 1419, 1426-27 (11th Cir. 1997)

(involving a chronic alcoholic dying from a withdrawal-induced seizure while in

pretrial detention after his wife warned jailers about his chronic alcoholism and

propensity for life-threatening seizures as he withdraws, directly applying Farmer, and

       11
           Later, the inmate’s parents visited the inmate in prison and reported to an assistant who
worked under the psychiatrist’s supervision that the inmate had suicidal thoughts. Fearing the
inmate might attempt suicide again, the parents urged the assistant to have the inmate transferred
to a hospital. The assistant did nothing and did not contact the psychiatrist. Twenty-four days
later, the inmate hung himself. Id. at 832-33.

                                                27
                                                27
holding sufficient evidence presented from which a jury could find that each defendant

“knew [the decedent] had urgent medical needs that would be significantly exacerbated

by delay,” that each defendant “planned to keep [the decedent] in jail without medical

supervision or treatment until he had a seizure,” and each defendant “delayed obtaining

treatment for [the decedent] until after he suffered a seizure”); Cottrell v. Caldwell, 85

F.3d 1480, 1490-91 (11th Cir. 1996) (involving an arrestee dying from positional

asphyxia while in a police car, directly applying Farmer, and holding no evidence to

support a jury finding that defendant police officers “were consciously aware of and

disregarded the risk that [decedent arrestee] would suffocate” as a result of defendants’

positioning and restraining decedent arrestee in police car); Adams v. Poag, 61 F.3d

1537, 1543-48 (11th Cir. 1995) (involving inmate with acute asthma and inability to

breathe, reversing the denial of qualified immunity, and holding that evidence created

fact issues regarding medical malpractice but not deliberate indifference).12 Although

helpful guidance, these three decisions do not involve deliberate indifference to

       12
          Although post-Farmer, Adams does not cite or discuss Farmer, but it nonetheless
stresses that in this Circuit “cases have consistently held that knowledge of the need for medical
care and an intentional refusal to provide that care constitutes deliberate indifference.” 61 F.3d
at 1543 (emphasis supplied).

                                               28
                                               28
psychiatric medical needs. Thus, we have focused instead on Steele and Greason,

which do.13

C.    Plaintiff’s Contentions

      We now apply the teachings of Farmer, Steele, and Greason to this case.

Plaintiff contends that Defendants’ medical care was grossly inadequate and that

Defendants knew their care was grossly inadequate. According to Plaintiff, the

medical care Defendants provided was grossly inadequate because Defendants

misdiagnosed her as having a polysubstance abuse disorder when they knew or should

have known she had bipolar disorder, discontinued medication that would have treated

her bipolar disorder, improperly used behavior modification techniques, and waited

       13
          The parties also cite this Court’s post-Farmer decisions in Dolihite v. Maughon, 74
F.3d 1027 (11th Cir. 1996), and Hale v. Tallapoosa County, 50 F.3d 1579 (11th Cir. 1995).
However, we focus on Steele as it involves the subjective element of deliberate indifference (as
opposed to the objective qualified immunity analysis in Dolihite) and psychiatric medical needs
(as opposed to inmate-on-inmate violence in Hale), and we discuss Greason because of Steele’s
reliance on it.
        Dolihite concerns a juvenile who hung himself while involuntarily civilly committed at a
state psychiatric facility, but the majority opinion does not cite Farmer or discuss the subjective
prong outlined in Farmer. Instead, the majority opinion in Dolihite addresses only the objective
prong of qualified immunity–whether “a reasonable professional in defendant’s shoes would
have known that his challenged actions (or inaction) violated plaintiff’s constitutional rights.”
Id. at 1046.
        In Hale, the plaintiff arrestee sued for damages arising from being beaten by other
occupants of an overcrowded, small “bullpen” with detainees not segregated based on proclivity
for violence or reasons for confinement. 50 F.3d at 1580-81. The case turned on whether
defendants knew about the significant risk of inmate-on-inmate violence but knowingly
disregarded that risk and kept the plaintiff arrestee in that bullpen. Id. at 1582-84. The Court
stressed the evidence that officials admitted knowing that inmate-on-inmate violence occurred in
that overcrowded “bullpen” on a regular basis and resulted in injuries requiring medical
treatment. Id. at 1583.

                                                29
                                                29
eight months before sending her outside the prison for diagnostic tests. Plaintiff also

submits expert testimony stating Defendants’ medical care was grossly inadequate,

while Defendants’ experts state Defendants complied with the applicable standard of

care.

        After review, we agree with the magistrate judge that Plaintiff has presented

insufficient evidence for a reasonable jury to find that Defendants knew that she had

bipolar disorder, that Defendants knew they had misdiagnosed her as suffering from

polysubstance abuse rather than bipolar disorder, or that Defendants otherwise knew

their treatment was grossly inadequate but proceeded with the treatment anyway.

Without evidence to establish the subjective mental intent prong of deliberate

indifference, Defendants are entitled to summary judgment under Farmer. We address

Plaintiff’s evidence against each Defendant in turn.

D.      Defendant Sikes

        Defendant Sikes is a psychiatrist who worked part time at GWCI. Sikes first met

with Plaintiff on June 3, 1991, a few days after her transfer to GWCI, and he gave the

order to discontinue her psychotropic medication. Sikes himself saw Plaintiff sixteen

times during the eight months before he determined that she needed to go to Central

for further mental health examination. Sikes was also consulted by mental health staff

                                           30
                                           30
on numerous other occasions, and he was repeatedly called upon to advise correctional

officers on how to respond to Plaintiff’s self-destructive behavior.

      Sikes’s liability turns on whether he knew Plaintiff had bipolar disorder, or knew

he was misdiagnosing Plaintiff, or knew his treatment was otherwise grossly

inadequate but proceeded with the treatment anyway. Sikes’s reports show he

diagnosed Plaintiff as suffering from polysubstance abuse, and Plaintiff agrees that

psychotropic medication is not proper treatment for polysubstance abuse. Plaintiff’s

complaint asserts principally that Sikes misdiagnosed her condition, that she had

bipolar disorder rather than merely suffering from polysubstance abuse, that her

behavior made it obvious that she had bipolar disorder, and that Sikes should have

known both that she was bipolar and that medication was the proper treatment for

bipolar disorder. In addition, Plaintiff argues any treatment she did receive was both

grossly inadequate and detrimental to her bipolar condition.

      1.     Facts Regarding Sikes’s Treatment

      Sikes is entitled to summary judgment on Plaintiff’s deliberate-indifference

claim because Plaintiff failed to present evidence from which a reasonable jury could

infer that Sikes knew she had bipolar disorder, or knew he was misdiagnosing Plaintiff,

or knew his treatment was otherwise grossly inadequate but proceeded with the

treatment anyway. See Steele, 87 F.3d at 1269; Greason, 891 F.2d at 835. Turning

                                          31
                                          31
first to the initial diagnosis and discontinuation of medication, the undisputed evidence

shows that Sikes discontinued Plaintiff’s medication only after Sikes personally

interviewed Plaintiff and reviewed a three-page report by Weathers, who had

performed an extensive review of Plaintiff’s history and symptoms.14 It is also

undisputed that Sikes, unlike the psychiatrists in Steele and Greason, conducted

multiple follow-up sessions and observed Plaintiff’s behavior repeatedly once she was

off medication; altogether, he met with Campbell sixteen times. Moreover, Weathers’s

report revealed the Cobb County jail told Weathers that Campbell’s suicidal threats

might be an attempt to manipulate officials as they were reducing her medication. In

stark contrast, the professionals previously responsible for the plaintiff inmates in

Steele and Greason stressed the inmates’ suicidal tendencies and prior psychiatric

diagnoses and urged continued medication.

      Plaintiff faults Sikes for not obtaining and reviewing her actual medical records

from the Cobb County jail or her prior thirteen hospitalizations as a juvenile.

However, Sikes reviewed (a) Weathers’s detailed summary of Weathers’s

communications with the Cobb County jail, which included an account of Campbell’s

symptoms and treatment at the jail, and (b) Weathers’s summary of Plaintiff’s personal

       14
          Sikes says he also performed an independent review of Plaintiff’s history, but Plaintiff
disputes that. We thus rely only on Sikes’s personal interview of Campbell and his review of
Weathers’s report.

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                                               32
history, which included an account of mental health problems as a juvenile and a prior

hospitalization.   Moreover, the jail records and prior hospitalization records

themselves, which are in evidence in this case, contain no diagnosis of bipolar disorder.

      Plaintiff also points to the fact that Sikes did know she was prescribed Trilafon

and lithium while at the Cobb County jail, which she says should have put Sikes on

notice she had bipolar disorder. However, the Cobb records themselves show Plaintiff

was placed on Trilafon and lithium without indicating a diagnosis of bipolar disorder.

Indeed, in an affidavit, Dr. Youngleson, who prescribed the medication at the jail,

testifies (1) that Plaintiff was never given any diagnosis while at the jail; (2) that

looking back, he believes Plaintiff suffered from a personality disorder rather than

bipolar disorder; and (3) that Plaintiff’s threats and self-destructive behavior seemed

manipulative. The jail records also show Cobb County jail officials’ concerns that

Plaintiff might be “running a game on us” and acting out to manipulate officials.

      Sikes’s ongoing medical treatment is also readily distinguishable from that in

Steele and Greason, where the psychiatrists basically did nothing to treat the inmates

after discontinuing their medication. See Adams v. Poag, 61 F.3d 1537, 1544 (11th

Cir. 1995) (noting that “when the need for medical treatment is obvious, medical care

that is so cursory as to amount to no treatment at all may constitute deliberate

indifference”). In stark contrast, Sikes spent a great deal of time and effort working

                                           33
                                           33
with Plaintiff. Sikes also recommended mental health counseling, consistent with his

stated diagnosis that Plaintiff suffered from polysubstance abuse.15 In addition, Sikes

had other medical staff members monitor Plaintiff’s behavior and symptoms, and he

took affirmative steps to prevent Plaintiff from harming herself and others. Such

actions readily distinguish Sikes’s care from the deliberate indifference in Steele and

Greason.16

      2.      Expert Testimony

      Lacking direct or circumstantial factual evidence to establish or to allow a jury

to infer Sikes’s knowledge, Plaintiff attempts to create a factual issue regarding Sikes’s

mental intent by submitting opinion testimony by medical experts. In affidavits and

depositions, Plaintiff’s experts testify that given Plaintiff’s prior hospitalizations and

medication and her symptoms and behavior, Sikes should have known that Plaintiff

had bipolar disorder and needed medication and that Sikes’s treatment was grossly

inadequate. In response, Defendants present expert testimony opining that Defendants’

medical care fully complied with the applicable standards of care and that reasonable

       15
          As noted above, Plaintiff was placed on the caseload of mental health counselor
Valarie Ford. Ford conducted 34 counseling sessions with Plaintiff and saw Plaintiff informally
on a near daily basis.
       16
           Such actions also readily distinguish this case from the deliberate refusal to give the
pre-trial arrestee any medical treatment in Lancaster v. Monroe County, Ala., 116 F.3d 1419,
1426-27 (11th Cir. 1997).

                                                 34
                                                 34
mental health professionals could have reached the same conclusions Defendants

reached and taken the same actions Defendants took. Plaintiff’s experts’ opinion

testimony directly contradicts that of Defendants’ experts.

      The question becomes whether the opinion testimony by Plaintiff’s experts here

creates a jury issue regarding Defendants’ subjective mental intent required by Farmer.

More specifically, the issue is this: since the facts and circumstances of this case do not

allow an inference that Sikes not only should have perceived the risk but also actually

did perceive it, does the opinion testimony by Plaintiff’s medical experts based on

those same facts and circumstances provide the missing Farmer link? The answer is

no.

      We begin by examining our precedent for guidance. This circuit has not

discussed directly the precise role of expert testimony in a post-Farmer decision

turning on the subjective mental intent of medical professionals sued for deliberate

indifference to an inmate’s serious psychiatric medical needs. Neither Steele nor

Greason relies on opinion testimony by medical experts as evidence that the

psychiatrist knew his care was grossly inadequate. In Steele the plaintiff presented no

expert testimony at all,17 and in Greason this Court relied on expert testimony only in

       17
           Indeed, another issue before the Steele Court was whether the district court had erred
in refusing to appoint an expert witness to assist the plaintiff. 87 F.3d at 1271. The Court
remanded for the district court to reconsider appointing an expert, noting that “the appropriate
standard of psychiatric care” was at issue and that “[e]xpert opinion on that issue and its

                                               35
                                               35
addressing the objective prong of deliberate indifference.18 Instead, the egregious facts

and circumstances in those cases created the requisite factual issue of deliberate

indifference or wanton conduct.

      The parties rely heavily on this Court’s treatment of expert affidavits in Dolihite

v. Maughon, 74 F.3d 1027 (11th Cir. 1996). However, like Greason, Dolihite

considers expert medical affidavits only in relation to the objective inquiry of qualified

immunity–whether a reasonable medical professional in the defendants’ position would

have known that the defendants’ actions violated the juvenile’s constitutional rights.19

Dolihite acknowledges that in the unique context of a claim of deliberate indifference

to medical needs, expert testimony is relevant to ascertaining the applicability of

qualified immunity:

      Our circuit has indicated that the testimony of medical experts can aid the
      court in determining whether qualified immunity is appropriate where

application here obviously might be important to the finder of fact.” Id.; see also Young v. City
of Augusta, 59 F.3d 1160, 1169-70 (11th Cir. 1995) (upholding the district court’s decision not
to appoint an expert to assist plaintiff Young because “[t]he presence of a genuine issue of fact
with respect to deliberate indifference to Young’s medical needs is apparent from the face of the
record” without any expert testimony).
       18
          Greason relies on expert testimony in listing what the defendant psychiatrist would
have known had he reviewed the inmate’s file before discontinuing medication: there was
testimony by a psychiatrist “that Greason possessed a great number of the characteristics
associated with a high suicide risk.” 891 F.2d at 835 n.11. It also relies on expert testimony
“that Greason received grossly inadequate care,” and it reaffirms a past case’s holding that “the
conflict among the experts concerning the propriety of the psychiatrist’s professional judgment
calls [must] be resolved by the jury.” Greason, 891 F.2d at 835.
       19
            See footnote 13 supra.

                                               36
                                               36
      allegations hinge upon the appropriateness of the actions of medical
      professionals, including mental health professionals.

Id. at 1046. Dolihite does not address the role of expert testimony in determining

whether a plaintiff has sufficient evidence of the subjective mental intent required for

a jury finding of deliberate indifference to serious medical needs under Farmer.

Indeed, the majority opinion in Dolihite does not even cite Farmer. Moreover,

Dolihite’s explanation for considering expert testimony is particular to the objective

qualified immunity inquiry:

      Such expert medical testimony, making reference to specific deficiencies
      in a defendant’s treatment and specific medically accepted standards
      might, in conjunction with the specific facts of a case, persuade a court
      that the medical defendant’s actions in the case were clearly as great a
      departure from appropriate medical standards as previous departures
      found unconstitutional in prior cases–i.e., might persuade a court that a
      reasonable professional in defendant’s shoes would have known that his
      challenged actions (or inaction) violated plaintiff’s constitutional rights.

Id. at 1046. Thus, Dolihite’s consideration of expert testimony in applying qualified

immunity’s objective standard does not answer our question about the role of expert

opinion testimony when applying Farmer’s subjective-intent requirement.

      In two other conditions-of-confinement cases since Farmer, the plaintiffs failed

to create triable issues regarding the defendants’ subjective mental intent. Each

opinion lends support to our ultimate conclusion regarding expert testimony, but

admittedly neither is squarely on point here. In Cottrell v. Caldwell, 85 F.3d 1480

                                          37
                                          37
(11th Cir. 1996), this Court held that the plaintiff’s expert affidavit regarding what

“was well known by police” was insufficient to create a jury issue regarding Farmer’s

subjective component. Id. at 1491. The Court explained that “such a conclusory

statement about police in general is not evidence about the mental state of these

defendant officers in particular.” Id. Although helpful guidance on the role of expert

testimony, Cottrell does not fully answer the question here for two reasons. First,

Cottrell involves expert affidavits about police officers’ positioning and restraining

arrestees in police cars, as opposed to expert medical testimony. Also, Cottrell appears

to rely in part on the conclusory nature of the affidavits, and not all the testimony

Plaintiff presents in this case is so conclusory.

       Similarly, in Adams v. Poag, 61 F.3d 1537, 1543-48 (11th Cir. 1995), this Court

examined the plaintiff’s expert testimony and found it failed to create a triable issue

regarding the defendants’ subjective intent. However, as noted above, Adams is

framed in terms of qualified immunity and does not cite Farmer.20 Moreover, Adams,

too, seems to rest on particular deficiencies in the wording of the affidavits at

issue–deficiencies that are present in a great deal of, but not all, the testimony Plaintiff

relies on in this case.

       20
            See footnote 12 supra.

                                            38
                                            38
      Lastly, in Hale v. Tallapoosa County, 50 F.3d 1579 (11th Cir. 1995), a post-

Farmer inmate-on-inmate violence case, we considered experts’ opinions, but only

where other factual evidence showed the defendant sheriff’s actual knowledge.

Considering all the evidence, we found a triable issue as to whether the defendant

possessed the subjective mental intent required by Farmer. Id. at 1583. Importantly,

however, our finding of a factual issue did not rest on expert testimony alone.

Although we noted the expert’s testimony that “given the conditions in the months

preceding [the attack], it was plainly foreseeable to a reasonable law enforcement

official that a violent attack was likely to occur,” we also stressed the defendant’s own

admission “that he knew that inmate-on-inmate violence was occurring on a regular

basis” and “that he knew the violence sometimes resulted in injuries requiring medical

treatment.” Id.

      Lacking a controlling application of Farmer’s standard, we turn to Farmer itself.

In Farmer, the Supreme Court made clear that the subjective mental intent prong

requires that the official actually know of a substantial risk of serious harm to the

inmate’s health and then disregard that risk. Farmer, 511 U.S. at 837. An “official’s

failure to alleviate a significant risk that he should have perceived but did not, while

no cause for commendation, cannot . . . be condemned as the infliction of punishment.”

                                           39
                                           39
Id. at 838. Under Farmer, proof that the defendant should have perceived the risk but

did not is insufficient. Id. at 838. Farmer also explains:

      When instructing juries in deliberate indifference cases with such issues
      of proof, courts should be careful to ensure that the requirement of
      subjective culpability is not lost. It is not enough merely to find that a
      reasonable person would have known, or that the defendant should have
      known, and juries should be instructed accordingly.

Id. at 843 n.8. Instead, the plaintiff must submit evidence that the medical professional

defendant actually was aware of the significant risk of serious harm but deliberately

proceeded with grossly inadequate treatment anyway.

      The issue of subjective mental intent under Farmer is different from whether

Sikes’s medical treatment was negligent or grossly inadequate. To decide the issue of

subjective mental intent under Farmer, a jury would inquire (1) whether Sikes was

aware of facts about Plaintiff from which he could draw the inference that his present

course of treatment presented a substantial risk of serious harm to Plaintiff and (2)

whether he actually drew that inference but persisted in the course of treatment

anyway. There is no direct or circumstantial evidence in this record from which the

jury could infer Sikes’s actual knowledge, and Plaintiff’s experts’ testimony does not

provide the missing link under Farmer–at least under the facts and circumstances of

this case. Indeed, allowing expert testimony that Sikes should or would have known

to raise a jury issue as to whether he actually knew effectively would nullify Farmer’s

                                           40
                                           40
requirement of subjective mental intent. The deficiency of the expert testimony here

arises not necessarily from the specific wording of the experts’ testimony–although

some of Plaintiff’s affidavits are lacking in many respects21–but from the inherent

       21
          While we do not rely on deficiencies in the wording of the expert affidavits, we do note
a few of their shortcomings. For example, the experts’ testimony contains many conclusory
statements that Defendants were deliberately indifferent that do not govern our assessment of the
evidence. See Dolihite, 74 F.3d at 1046-47 & n.33 (explaining that “an expert opinion which is
merely conclusory, even if couched in the language of the relevant legal standard, will be of little
assistance to a court”); Cottrell, 85 F.3d at 1491 (“[A] conclusory statement about police in
general is not evidence about the mental state of these defendant officers in particular.”); Rogers
v. Evans, 792 F.2d 1052, 1062 n.9 (11th Cir. 1986) (holding that an affidavit “phrased in
conclusory terms” was “defective to create a factual dispute”).

       In addition, some of the affidavits rest on false factual predicates. For instance, the
opinion of James S. Cheatham, M.D., seems to rely in part on the assumption that Plaintiff had
been diagnosed as suffering for bipolar disorder prior to entering GWCI. Neither the Cobb
County jail records nor the other medical records in evidence contain a prior diagnosis of bipolar
disorder.

         Also, of the expert affidavits Plaintiff presents, the principal affidavit that opines about
what medical professionals would know is by John R. Paddock, who has a Ph.D. in psychology.
Dr. Paddock reviews the behavior Defendants observed and the treatment they implemented and
states, “Any person with professional credentials in the area of mental illness or the treatment of
mental or emotional disorders would know that what the Defendants were doing was grossly
improper in design, approach, and implementation.” In certain areas, such as prescribing
medicine, the training of psychologists and psychiatrists is not equivalent; thus, Dr. Paddock is
not a competent expert to testify to what a psychiatrist like Sikes would know about the need to
prescribe medicine.

         Finally, there is the opinion statement of Kenneth I. Robbins, M.D. that Sikes’s own
testimony “demonstrates he knew his behavior was improper.” However, Sikes’s testimony
itself either does or does not prove knowledge. Dr. Robbins’s opinion about what Sikes’s
testimony shows is not probative. Moreover, Sikes’s testimony, that Dr. Robbins refers to here,
does not demonstrate that Sikes knew his behavior was improper. What Dr. Robbins is referring
to here is that Sikes testified restraints were only to be used in limited situations and that Sikes
left his patient in restraints over a weekend. Dr. Robbins concludes from Sikes’s testimony
about the limited use of restraints that Sikes knew leaving Plaintiff in restraints over a weekend
was improper. However, Dr. Robbins fails to note the undisputed evidence that other
psychiatrists were on call that weekend, that they were available to answer correctional officers’

                                                41
                                                41
opinion nature of expert testimony about what a person should or would have known.

The particular conflicting expert testimony here demonstrates only that there is a

difference of opinion among professionals about what is accepted practice within the

psychiatric community and what a doctor should or would know. Plaintiff’s experts’

testimony here at best allows an inference by the jury that a doctor should have

perceived the risk of serious harm but not an inference that the doctor actually did

perceive the risk and persisted in his course of treatment anyway.22

questions, and that they were called upon every twenty-four hours to reassess the continued need
for restraints. Thus, Sikes’s testimony does not create a factual issue regarding Sikes’s
knowledge that his care was grossly inadequate–nor does Dr. Robbins’s opinion about Sikes’s
testimony.
       22
          We located one post-Farmer circuit court decision squarely addressing whether expert
medical testimony can create a factual issue about subject mental intent in cases involving
deliberate indifference to serious medical needs. In McKee v. Turner, No. 96-3446 (6th Cir.
Aug. 25, 1997), the Sixth Circuit held the defendant psychiatrist was entitled to summary
judgment because there was no evidence showing that the psychiatrist had acted with deliberate
indifference. The expert’s affidavit stated that the defendant psychiatrist had departed from
accepted standards of medical care and that the risk of suicide “must have been obvious” to the
defendant psychiatrist. The Sixth Circuit held that this affidavit was insufficient to support a
finding of deliberate indifference, stressing that under Farmer, “the official’s conduct is judged
by what he actually knew, not by what a reasonable person in his shoes would have known.”
The Sixth Circuit concluded:

       The issue here is not whether Dr. Morcos committed medical malpractice, but
       rather whether Dr. Morcos had knowledge or facts about [Plaintiff] from which he
       could draw the inference that his present course of treatment presented a
       substantial risk of serious harm to [Plaintiff], and that he actually drew that
       inference, but persisted in the course of treatment anyway. There is nothing in the
       record demonstrating this.

124 F.3d 198; see also Williams v. Mehra, 135 F.3d 1105 (6th Cir.), vacated and set for reh’g en
banc, 144 F.3d 428 (6th Cir. 1998).

                                                42
                                                42
      Of course, rarely if ever will a defendant medical professional admit that he

knew his course of treatment was grossly inadequate but proceeded with that treatment

anyway. Therefore plaintiffs necessarily must use circumstantial evidence to establish

subjective mental intent. See Farmer, 511 U.S. at 842; Lancaster v. Monroe County,

116 F.3d 1419, 1426 (11th Cir. 1997); Steele, 87 F.3d at 1269.

      But expert opinion testimony is not essential to that task. For example, in both

Steele and Greason, the plaintiffs created triable issues regarding the defendants’

knowledge without any expert opinion testimony by presenting evidence of the

particular facts and circumstances in those cases.23 As noted above, the doctor in

Steele stopped Steele’s medication after a “less than one minute” meeting and without

reviewing medical records.         More importantly, the doctor proceeded with no

medication in the face of warnings from the prior institution that the plaintiff was a

suicide risk, had tried suicide twice, and needed psychotropic medication. The doctor’s

conduct was similar in Greason: he saw Greason for a few minutes, promptly

concluded that Greason’s condition had stabilized, and discontinued Greason’s

medications without reviewing the clinical file or assessing Greason’s mental status to

determine his potential for suicide. The letters in the clinical file showed Greason was

       23
           See also Lancaster v. Monroe County, 116 F.3d 1419, 1426-29 (11th Cir. 1997)
(finding defendants’ own testimony regarding their knowledge and other evidence that the
defendants were personally warned of the detainee’s condition created triable issues regarding
defendants’ subjective mental intent without any expert testimony).

                                              43
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a schizophrenic, had suicidal tendencies, and needed medication. In both Greason and

Steele, this Court relied on facts and circumstances that made the risk of grossly

inadequate care and suicide so obvious that a jury could infer the defendants’ actual

knowledge. In contrast, here there was no prior diagnosis of bipolar disorder, and the

jail officials advised that they did not consider Plaintiff’s suicide threats to be serious

and that they perceived Plaintiff’s aberrant behavior as an attempt to manipulate

officials.

       Because Plaintiff has not presented sufficient direct or circumstantial evidence

to create a factual issue regarding Sikes’s subjective mental intent and the experts’

opinion testimony here does not provide the missing link, we affirm the magistrate

judge’s decision to grant Sikes summary judgment on Plaintiff’s deliberate-

indifference claim.

E.     Defendant Moore

       Defendant Moore was a licensed psychologist who worked one day a week at

GWCI.24 Unlike Sikes, Moore could not prescribe medication. Moreover, because

Moore worked at GWCI only one day a week, his duties and responsibilities were

        24
             On December 7, 1998, Moore’s counsel filed notice that Moore had died on November
22, 1998.

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decided week by week on an as-needed basis. Moore saw Plaintiff six times between

August and October 1991. His last contact with Plaintiff was on October 24, 1991.

      Plaintiff has failed to present sufficient evidence for a reasonable jury to find

Moore knew that Plaintiff had bipolar disorder or that his treatment was grossly

inadequate. Moore diagnosed Plaintiff as having a personality disorder, as opposed to

a mental illness, and Plaintiff has presented no evidence that Moore knew his diagnosis

was incorrect. Plaintiff’s primary contention is that Moore should have performed

psychological tests even though Sikes did not order them. Again, Plaintiff presents

expert testimony about Moore’s care, which might establish Moore breached the

standard of care and was negligent but does not support a finding that Moore knew

Plaintiff was misdiagnosed and needed medication or knew his care was otherwise

inadequate.25 Without evidence of Moore’s subjective intent, Plaintiff’s deliberate-

indifference claim cannot succeed.

F.    Defendant Ford

      Defendant Ford is a mental health counselor, untrained in diagnosing mental

illness and unauthorized to prescribe medication. Plaintiff was assigned to Ford for

       25
          Some of the expert testimony about Moore’s care seems to rest on the erroneous
assumption that Moore’s knowledge about Plaintiff was commensurate with Sikes’s. However,
as with Sikes, we do not rely on particular deficiencies in the affidavits.

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counseling during most of the eight-month period in question. Ford had almost daily

contact with Plaintiff.

      Plaintiff focuses on two alleged deficiencies in the care Ford provided. First,

Plaintiff points to an October 1991 memorandum Ford wrote to prison security

personnel instructing that they impose maximum disciplinary penalties for Plaintiff’s

infractions of prison rules. The memorandum states that Plaintiff had received

seventeen prior disciplinary reports, that Plaintiff had been evaluated several times by

Drs. Moore and Sikes, that Plaintiff “does not currently have an Axis I diagnosis,” and

that therefore “[t]he current treatment goal for Ms. Campbell as recommended by Dr.

Sikes and the mental health staff is behavior modification.”

      There is no evidence to support a jury finding that by writing the security

memorandum Ford was deliberately indifferent to Plaintiff’s serious medical needs.

First, the memorandum also states that “[m]edical staff will be responsible for ensuring

that medical needs are met according to policy.” Second, Plaintiff has presented no

evidence that Ford knew Plaintiff suffered from bipolar disorder–much less that Ford

knew Plaintiff’s self-destructive and defiant behavior stemmed from bipolar disorder.

 Moreover, Ford wrote this memorandum at Sikes’s direction, acting on the express

instructions of a medical doctor who was trained in diagnosis of mental illness, had

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diagnosed Plaintiff with polysubstance abuse and not bipolar disorder, and had

recommended behavior modification treatment as opposed to medication.

      Second, Plaintiff faults Ford for the overnight “delay in treatment” once it had

been determined that Plaintiff needed to go to Central for further evaluation. It is

undisputed that on the night of January 29, Ford knew it had been determined that

Plaintiff should be sent to Central. It is also undisputed that officials secured Plaintiff

in four-point restraints overnight and sent her to Central the next morning. Plaintiff

alleges that it was Ford’s decision to delay the transfer and that Ford decided to apply

four-point restraints without a prior order from a medical doctor.26

      Again, however, Plaintiff has presented no evidence that Ford knew that Plaintiff

had bipolar disorder or that such overnight delay amounted to grossly inadequate care.

Dr. Paddock’s affidavit purports to support a finding that Ford “had to know” the care

Plaintiff received was grossly inadequate:

      Defendant Ford was in a position and exercising responsibility in which
      she would have had to know that further and additional mental
      health/psychological evaluation and assessment of Ms. Plaintiff were
      required by her and consistent with the competencies of other members
      of the treatment team (e.g., licensed psychologists and psychiatric
      physicians), and that the acts undertaken were grossly deficient.

       26
         According to Plaintiff, the medical doctor’s order approving the four-point restraints
used on this occasion was signed almost two months later on March 24, 1991.

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As discussed regarding Sikes, this expert affidavit does not suffice to support a finding

that Ford knew her care was grossly inadequate but persisted in that treatment. At best,

it might support a finding that Ford’s care was grossly inadequate or a finding that

Ford should have known or perceived–or “had to know”–her care was grossly

inadequate. However, as explained above, “[t]here is no liability for ‘an official’s

failure to alleviate a significant risk that he should have perceived but did not . . . .’”

Cottrell v. Caldwell, 85 F.3d 1480, 1491 (11th Cir. 1996) (citing Farmer, 511 U.S. at

838).

G.      Defendant Gavin

        Plaintiff acknowledges that Defendant Gavin, the GWCI warden, was not

employed as a mental health professional. Plaintiff claims only that Gavin was

deliberately indifferent in supervising others who were deliberately indifferent to her

serious medical needs. By its own terms, Plaintiff’s claim against Gavin cannot

succeed without evidence of an underlying constitutional violation by one of the

mental health professionals. As explained above, the record contains no such evidence.

Thus, Gavin is necessarily entitled to summary judgment on this claim.27

                                    VI. EXCESSIVE FORCE

        27
             Plaintiff’s supervisory liability claim against Sikes fails for the same reason.

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                                                    48
      Plaintiff also claims that even if Defendants’ actions did not amount to

deliberate indifference to her serious medical needs, their use of restraints constituted

excessive force.

A.    Proof Required that Force Used Maliciously and Sadistically to Cause
      Harm

      The Eighth Amendment’s proscription of cruel and unusual punishments also

governs prison officials’ use of force against convicted inmates. See Whitley v.

Albers, 475 U.S. 312, 327 (1986) (holding that “the Due Process Clause affords

[convicted prisoners] no greater protection than does the Cruel and Unusual

Punishments Clause”). To establish an Eighth Amendment claim for excessive force,

however, Plaintiff must meet an intent requirement more stringent than Farmer’s

deliberate-indifference standard: she must prove that “force was applied . . .

maliciously and sadistically for the very purpose of causing harm.” Whitley, 475 U.S.

at 320-21 (quoting Johnson v. Glick, 481 F.2d 1028, 1033 (2d Cir. 1973)); see also

Hudson v. McMillian, 503 U.S. 1, 6-7 (1992).

      Discussing this heightened specific-intent requirement in Whitley, the Supreme

Court reiterated that force does not violate the Eighth Amendment merely because it

is unreasonable or unnecessary: “The infliction of pain in the course of a prison

security measure . . . does not amount to cruel and unusual punishment simply because

it may appear in retrospect that the degree of force authorized or applied for security

                                           49
                                           49
purposes was unreasonable, and hence unnecessary in the strict sense.” 475 U.S. at

319. Reviewing the force used to quell a prison riot in Whitley, the Court explained

that “whether the measure taken inflicted unnecessary and wanton pain and suffering

ultimately turns on ‘whether force was applied in a good faith effort to maintain or

restore discipline or maliciously and sadistically for the very purpose of causing

harm.’” Id. at 320-21 (quoting Johnson, 481 F.2d at 1033).

      Subsequently, in Hudson v. McMillian, 503 U.S. 1 (1992), the Supreme Court

extended Whitley’s holding outside the prison-riot context and applied the same

heightened intent requirement to force used as a prophylactic, preventive measure. See

Whitley, 475 U.S. at 322 (acknowledging the distinction). The Hudson Court held that

“whenever prison officials stand accused of using excessive physical force in violation

of the Cruel and Unusual Punishments Clause, the core judicial inquiry is that set out

in Whitley: whether force was applied in a good-faith effort to maintain or restore

discipline, or maliciously and sadistically to cause harm.” Id. at 6-7. The Court

reasoned that even absent the exigency present during a riot-like disturbance,

“‘“[p]rison administrators . . . should be accorded wide-ranging deference in the

adoption and execution of policies and practices that in their judgment are needed to

preserve internal order and discipline and to maintain institutional security.”’” Hudson,

503 U.S. at 7 (quoting Whitley, 475 U.S. at 321-22 (quoting Bell v. Wolfish, 441 U.S.

                                           50
                                           50
520, 547 (1979))). Thus, Hudson dictates that Whitley’s standard–force applied

maliciously and sadistically to cause harm–applies to all claims that prison officials

used excessive force against convicted prisoners.

      In addition to defining the mental state required, Hudson and Whitley outline

five distinct factors relevant to ascertaining whether force was used “maliciously and

sadistically for the very purpose of causing harm”: (1) “the extent of injury”; (2) “the

need for application of force”; (3) “the relationship between that need and the amount

of force used”; (4) “any efforts made to temper the severity of a forceful response”; and

(5) “the extent of the threat to the safety of staff and inmates, as reasonably perceived

by the responsible officials on the basis of facts known to them.” Whitley, 475 U.S.

at 321; see also Hudson, 503 U.S. at 7. Whitley also narrows the precise inquiry

applicable when deciding whether officials are entitled to judgment as a matter of law:

      courts must determine whether the evidence goes beyond a mere dispute
      over the reasonableness of a particular use of force or the existence of
      arguably superior alternatives. Unless it appears that the evidence,
      viewed in the light most favorable to the plaintiff, will support a reliable
      inference of wantonness in the infliction of pain under the standard we
      have described, the case should not go to the jury.

Whitley, 475 U.S. at 322 (emphasis added).

B.    Eleventh Circuit Applications

                                           51
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      Plaintiff’s excessive-force claim focuses on restraints Defendants used while she

was in isolation. Thus, we review prior decisions of this Court applying Whitley to

uses of restraints and isolation.

      Affirming summary judgment in Williams v. Burton, 943 F.2d 1572 (11th Cir.

1991), this Court held that the officials’ using four-point restraints and a gag was not

excessive force. Officials placed Williams in four-point restraints, with gauze and tape

over his mouth, for twenty-eight and one-half hours. Id. at 1574. There were only

brief intervals for eating, physical exercise, and toilet use. Id. Noting that Williams

had threatened to kill officials, spat on them, and thrown bodily fluids at them, this

Court explained that the four-point restraints and gag were not excessive force but were

used to prevent Williams from harming himself or officials:

      [t]he four-point restraints were used to reduce or eliminate Williams’
      ability to inflict physical harm against either himself or the correction
      officers. The restraints were not used for the purpose of inflicting pain.
      The gauze padding and tape were used to prevent Williams from
      encouraging further unrest among the other inmates in the segregation
      unit, as well as to protect the officers from his continuing spital assault.

Id. at 1575. Also important to the Williams decision were the observations (1) that

although the inmate “experienced some discomfort because of his restraint, no actual

injury was inflicted” id.; and (2) that “constant monitoring and examinations by

medical personnel” were adequate to safeguard the inmate’s well-being. Id.

                                          52
                                          52
      Williams stresses that courts should afford great deference to prison officials

regarding the use of restraints as a prophylactic or preventive measure, stating:

      How long restraint may be continued calls for the exercise of good
      judgment on the part of prison officials. Once it is established that the
      force was applied in a good faith effort to maintain discipline and not
      maliciously or sadistically for the purpose of causing harm, the courts
      give great deference to the actions of prison officials in applying
      prophylactic or preventive measures intended to reduce the incidence of
      riots and other breaches of prison discipline.

Id. at 1576 (internal citations omitted).       This Court also found the officials’

“continuous observation and management of Williams during his restraint” showed

their good faith, and we concurred with the district court’s holding that “Williams’

history of persistent disobedience and the potential for a disturbance in the segregation

unit justified the continued use of the restraints and gag until the officers were

reasonably assured that the situation had abated.” Id.

      Similarly, in Sims v. Mashburn, 25 F.3d 980 (11th Cir. 1994), this Court upheld

the officials’ use of a stripped cell for twenty-nine hours and reversed the district

court’s grant of judgment for the inmate. The inmate in Sims hung various items over

the window to his cell, preventing prison officials from observing his behavior; he

placed a towel in the toilet, which officers took as an implicit threat to flood the

segregation unit; and he threatened that if officials entered his cell, “I’ll buck; you’ll

have to kill me.” Id. at 981. On that basis, officials stripped his cell and removed all

                                           53
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clothing except his undershorts, and they disconnected the water to his toilet. Id. at

981-82.

      In determining whether the officials had used good faith or acted “maliciously

and sadistically to cause harm,” this Court observed that the officers had followed the

prison’s operating procedures for stripping cells, which required, among other things,

documenting the incident and checking on the inmate’s status every fifteen minutes.

Id. at 985-86. Again, we emphasized that compliance with an established prison policy

evidences an official’s good faith, particularly when, as in Sims, “[t]he policy itself

reflects a well-developed and planned procedure.” Id. at 986. In the field of prison

discipline, “prison officials, not judges, are experts.” Id.

C.    Application To This Case

      Plaintiff focuses on the instances in which officials used the “L” shape restraint

in addition to the straightjacket. The record reflects that officials used the “L” shape

restraint at least five different times for periods of twenty-seven hours on September

18 to 19, one hour and twenty-five minutes on September 22, five hours on October

12 to 13, sixteen hours on October 23 to 24, and sixty-six hours and forty minutes on

October 25 to 28.

      As explained above, Plaintiff’s excessive-force claim depends on whether these

periods of restraint were instituted “maliciously and sadistically for the very purpose

                                           54
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of causing harm.” Precedent dictates that this determination be guided by the five

Hudson/Whitley factors outlined above, by deference to prison officials’ punitive

judgments, and by this Court’s previous holdings that compliance with prison policies

evidences officials’ good faith. For several reasons, such considerations convince us

that the record here does not create a factual issue regarding malicious or sadistic

intent.

          First, the urgent need for force was readily apparent each time the “L” shape

restraint was applied; the undisputed facts show Plaintiff posed a serious threat to

herself and to others. Plaintiff not only told officials that she was considering suicide

but also actually took steps toward harming herself on more than one occasion. When

the “L” shape restraint was applied initially in September 1991, officials found her

standing on the bed with a sheet around her neck. As noted above, on other occasions,

she thrashed about her cell, climbed up on the sink, ripped her sheets to shreds, beat

on and dismantled the overhead light, and attempted to obtain sharp objects. Plaintiff

also bit and scratched prison officials, and she repeatedly threatened to “hurt

someone.” Some of Plaintiff’s actions posed a security risk as well. She regularly

threatened to flood the toilet, and she often started fires in her cell, burning such items

as her food tray, her Bible, and her clothing. One clothing fire mandated evacuation

of her entire cellblock.

                                            55
                                            55
      Moreover, lesser restraints were ineffective in curbing Plaintiff’s dangerous

behavior. Plaintiff freed herself from straightjackets on multiple occasions. In

addition, on one occasion when officials used only a straightjacket, Plaintiff began

banging her head and kicking.

      Although resulting in physical discomfort and emotional pain, the restraints

undisputedly caused Plaintiff no physical injury. More importantly, the officers

carefully monitored Plaintiff’s physical condition while she was restrained. They

checked Plaintiff’s circulation each time they applied the “L” shape method of

restraint, and security officers checked Plaintiff every fifteen minutes while she was

restrained. There were also regular checks by medical staff, with a nurse evaluating

Plaintiff’s condition every few hours and a doctor reassessing the need for restraints

every twenty-four hours.

      Additionally, the severity of the restraint was tempered somewhat by attention

to Plaintiff’s basic physical needs. During periods of restraint, Plaintiff was given

“toileting” on request,28 offered meals at regular intervals, and sometimes given a

mattress rather than being made to lie on the floor.

       28
           Plaintiff asserts that there was one instance in which she urinated on herself while in
restraints and the situation was not discovered for some hours.

                                                56
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      Also evidencing the officials’ good faith is their compliance with prison

procedures for using restraints. GWCI policies provide for extensive documentation

and monitoring when restraints are used, and Defendants met and exceeded those

requirements.      For example, in addition to completing the required written

documentation, Defendants videotaped some of the instances in which they used the

“L” shape restraint.29

      In addition, on at least two different occasions, Sikes declined to approve

restraints when other officials requested them. Each time, Sikes instructed the

requesting officials that restraints should not be applied when Plaintiff did not pose a

threat to her own safety. Such decisionmaking by Sikes hardly betrays a malicious or

sadistic motive.

       Plaintiff provides no viable reason to depart from the conclusion dictated by

these considerations. Her main contention is that four-point restraints would have been

equally effective and less dehumanizing than the “L” shape. In addition, she points to

a deputy prison commissioner’s testimony that he was shocked to hear that prisoners

were being “hog-tied.” However, such evidence raises “a mere dispute over the

reasonableness of a particular use of force or the existence of arguably superior

       29
         Plaintiff entered in the record before the magistrate judge a videotape of several “L”
shape incidents, and that tape is part of the record on appeal as well.

                                               57
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alternatives,” Whitley, 475 U.S. at 322, and would not suffice to support a jury finding

that the officials restrained Plaintiff in this manner “maliciously and sadistically for the

very purpose of causing harm.” Id. at 320-21.

       There is also no showing that the “L” shape method of restraint used here

violated prison policies.30 Both GDOC and GWCI policies clearly allowed restraints

to be used to curb dangerous behavior, and neither policy forbade this particular

method of restraint. GDOC operating procedures merely authorized restraints “to

prevent the inmate from hurting himself or others” and defined “hard restraints” versus

“soft restraints.” GDOC Standard Operating Procedure No. VC01-0014 (Revised Oct.

1, 1989).31 Similarly, GWCI policy authorized restraints as “a temporary means of

controlling an inmate’s destructive behavior toward herself and others.” GWCI Policy

Statement No. 801.1 (activated Nov. 1, 1989; revised June 13, 1991). GWCI policy

also examined the costs and benefits of several different methods of restraint, noting

that “[t]he following comments should be reviewed and considered in making a

decision as to which devices to use when restraint is necessary.” Id. The “L” shape

       30
           It is far from clear in the case law that officials’ violating prison policy would
necessarily establish the requisite subjective mental intent. In this case, however, because there
is insufficient evidence to support a finding that prison policies were violated, we need not
address whether a violation of prison policies is per se malicious and sadistic.
       31
          We refer to the policies in effect when the challenged instances of restraint occurred.
There is some indication in the record that since that time, the policies may have been amended
to proscribe “hog-tying.”

                                                58
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method used here was not expressly listed, but GWCI policy expressly provided in a

separate subsection that a physician might “also consider other options as to the

method of restraint most likely to be appropriate.” Id.

      Plaintiff argues that the absence of “hog-tying” from the lists of possible

restraint methods meant the “L” shape method used here was forbidden. In support of

that contention, she offers the testimony of a deputy prison commissioner who

interpreted the state operating procedures to ban “hog-tying.” However, the deputy

commissioner’s testimony is insufficient to create a triable issue in the face of the clear

and unambiguous language of the policies themselves, which did not ban or in any way

proscribe this method of restraint but instead expressly permitted doctors to consider

using other methods of restraint.

                                 VII. CONCLUSION

      Because we find insufficient evidence to support a jury’s finding that any of the

Defendants possessed the subjective mental intent required to support Plaintiff’s

deliberate-indifference and excessive-force claims, the magistrate judge’s grant of

summary judgment for Defendants Sikes, Moore, Gavin, and Ford is AFFIRMED.

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