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Solitary Confinement and Mental Illness in US Prisons

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Solitary Confinement and Mental Illness in US Prisons ANALYSIS AND COMMENTARY Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics Jeffrey L. Metzner, MD, and Jamie Fellner, Esq. In recent years, prison officials have increasingly turned to solitary confinement as a way to manage difficult or dangerous prisoners. Many of the prisoners subjected to isolation, which can extend for years, have serious mental illness, and the conditions of solitary confinement can exacerbate their symptoms or provoke recurrence. Prison rules for isolated prisoners, however, greatly restrict the nature and quantity of mental health services that they can receive. In this article, we describe the use of isolation (called segregation by prison officials) to confine prisoners with serious mental illness, the psychological consequences of such confinement, and the response of U.S. courts and human rights experts. We then address the challenges and human rights responsibilities of physicians confronting this prison practice. We conclude by urging professional organizations to adopt formal positions against the prolonged isolation of prisoners with serious mental illness. J Am Acad Psychiatry Law 38:104–8, 2010 Physicians who work in U.S. prison facilities face regation (i.e., locked-down housing) units within ethically difficult challenges arising from substan- regular prisons, tens of thousands of prisoners spend dard working conditions, dual loyalties to patients years locked up 23 to 24 hours a day in small cells and employers, and the tension between reasonable that frequently have solid steel doors. They live with medical practices and the prison rules and culture. In extensive surveillance and security controls, the ab- recent years, physicians have increasingly confronted sence of ordinary social interaction, abnormal envi- a new challenge: the prolonged solitary confinement ronmental stimuli, often only three to five hours a of prisoners with serious mental illness, a corrections week of recreation alone in caged enclosures, and practice that has become prevalent despite the psy- little, if any, educational, vocational, or other pur- chological harm it can cause. There has been scant poseful activities (i.e., programs). They are hand- professional or academic attention to the unique eth- cuffed and frequently shackled every time they leave ics-related quandary of physicians and other health- their cells.3–5 The terms segregation, solitary con- care professionals when prisons isolate inmates with finement, and isolation will be used interchangeably mental illness. We hope to begin to fill this gap. to describe these conditions of confinement. Solitary confinement is recognized as difficult to Isolation can be psychologically harmful to any withstand; indeed, psychological stressors such as prisoner, with the nature and severity of the impact isolation can be as clinically distressing as physical depending on the individual, the duration, and par- torture.1,2 Nevertheless, U.S. prison officials have in- ticular conditions (e.g., access to natural light, books, creasingly embraced a variant of solitary confinement to punish and control difficult or dangerous prison- or radio). Psychological effects can include anxiety, ers. Whether in the so-called supermax prisons that depression, anger, cognitive disturbances, perceptual have proliferated over the past two decades or in seg- distortions, obsessive thoughts, paranoia, and psychosis.6 Dr. Metzner is Clinical Professor of Psychiatry, University of Colorado The adverse effects of solitary confinement are es- School of Medicine, Denver, CO. Jamie Fellner is Senior Counsel, pecially significant for persons with serious mental U.S. Program, Human Rights Watch, New York, NY. Address corre- spondence to: Jeffrey L. Metzner, MD, 3300 East First Ave., Suite 590, illness, commonly defined as a major mental disorder Denver, CO 80206. E-mail: [email protected]. (e.g., schizophrenia, bipolar disorder, major depres- Disclosures of financial or other potential conflicts of interest: None. sive disorder) that is usually characterized by psy- 104 The Journal of the American Academy of Psychiatry and the Law Metzner and Fellner chotic symptoms and/or significant functional im- cials have been reluctant to provide the funds and pairments. The stress, lack of meaningful social leadership needed to ensure that prisons have suffi- contact, and unstructured days can exacerbate symp- cient mental health resources. Twenty-two of 40 toms of illness or provoke recurrence.7 Suicides occur state correctional systems reported in a survey that disproportionately more often in segregation units they did not have an adequate mental health staff.13 than elsewhere in prison.8–10 All too frequently, Persons with mental illness are often impaired in mentally ill prisoners decompensate in isolation, re- their ability to handle the stresses of incarceration quiring crisis care or psychiatric hospitalization. and to conform to a highly regimented routine. They Many simply will not get better as long as they are may exhibit bizarre, annoying, or dangerous behav- isolated. ior and have higher rates of disciplinary infractions Mental health professionals are often unable to than other prisoners. Prison officials generally re- mitigate fully the harm associated with isolation. spond to them as they do to other prisoners who Mental health services in segregation units are typi- break the rules. When lesser sanctions do not curb cally limited to psychotropic medication, a health the behavior, they isolate the prisoners in the segre- care clinician stopping at the cell front to ask how the gation units, despite the likely negative mental health prisoner is doing (i.e., mental health rounds), and impact. Once in segregation, continued misconduct, occasional meetings in private with a clinician.7 In- often connected to mental illness, can keep the in- dividual therapy; group therapy; structured educa- mates there indefinitely.7,14 tional, recreational, or life-skill-enhancing activities; In class action cases challenging the segregation of and other therapeutic interventions are usually not inmates with serious mental illness as unconstitu- available because of insufficient resources and rules tionally cruel because of the psychological harm it requiring prisoners to remain in their cells.11 can inflict, U.S. federal courts have either issued rul- The use of segregation to confine the mentally ill ings or accepted settlements that prohibit or sharply has grown as the number and proportion of prisoners curtail the practice. According to one federal judge, with mental illness have grown. Although designed putting mentally ill prisoners in isolated confine- and operated as places of punishment, prisons have ment “is the mental equivalent of putting an asth- nonetheless become de facto psychiatric facilities de- matic in a place with little air....”15 Unfortunately, spite often lacking the needed mental health servic- except in the small number of prisons governed by es.7 Studies and clinical experience consistently indi- the outcome of such litigation, mentally ill prisoners cate that 8 to 19 percent of prisoners have psychiatric continue to be sent to segregation; indeed, they are disorders that result in significant functional disabil- often disproportionately represented in segregation ities, and another 15 to 20 percent require some form units.16,17 of psychiatric intervention during their incarcera- International treaty bodies and human rights ex- tion.12 Sixty percent of state correctional systems re- perts, including the Human Rights Committee,18 sponding to a survey on inmate mental health re- the Committee against Torture,19,20 and the U.N. ported that 15 percent or more of their inmate Special Rapporteur on Torture,21 have concluded population had a diagnosed mental illness.13 that solitary confinement may amount to cruel, in- Despite significant improvements in correctional human, or degrading treatment in violation of the mental health services, often related to litigation and International Covenant on Civil and Political development of standards and guidelines by the Na- Rights22 and the Convention against Torture and tional Commission on Correctional Health Care other Cruel, Inhuman, and Degrading Treatment or (NCCHC), the American Psychiatric Association Punishment.23 They have specifically criticized su- (APA), and other professional organizations, in permax confinement in the United States because of many prisons the services remain woefully inade- the mental suffering it inflicts.19,20 Whatever one’s quate. Relative to the number of prisoners needing views on supermax confinement in general, human help, there is an insufficient number of qualified rights experts agree that its use for inmates with seri- staff, too few specialized facilities, and few pro- ous mental illness violates their human rights. grams.7 Mindful of budget constraints and scant Principles of ethics regarding beneficence, nonma- public support for investments in the treatment (as leficence, and respect for the rights and dignity of all opposed to punishment) of prisoners, elected offi- patients have led international and national profes- Volume 38, Number 1, 2010 105 Solitary Confinement and Mental Illness sional organizations to affirm that physicians are eth- Publically exposing and urging change in harmful ically obligated to refrain from countenancing, con- prison practices is difficult and, needless to say, can doning, participating in, or facilitating torture
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