Monday, June 09, 2008

Leave Me Alone: The Science Of Solitary Confinement

Solitary confinement, or segregation, is used for several reasons. Inmates are put into segregation as a disciplinary measure for doing things like threatening or fighting with officers, escaping, destroying state property or setting fires. Segregation is used for medical reasons for inmates who may have infectious diseases (like tuberculosis) or who are refusing evaluation for infectious diseases. Segregation is used for protective custody if the inmate is a juvenile or if there are reasons to believe the inmate's safety might be at risk in regular housing (also called general population). Finally, there are also mental health reasons for putting someone in segregation. Inmates who are new to the facility, who are frightened and need time to adjust, or who have had a recent trauma or loss may temporarily be put by themselves to give them a quiet place to deal with whatever is going on.

In free society segregation is used for therapeutic reasons too, although the terminology changes. On an inpatient unit "segregation" becomes "seclusion" even though the physical conditions may be identical, or very similar to, the physical environment in a prison. Seclusion rooms and segregation cells are usually bare with minimal comforts. The patient (or inmate) is deprived of access to outside resources and supports, with no regular recreation or entertainment. The food is, well, institutional food is institutional food.

The only real difference is that in free society when someone is put in seclusion there must be a clinical evaluation that finds an indication for using this intervention, usually unpredictability or evidence that the patient may be a danger to himself or others. The indication is documented and the patient is usually also observed at regular intervals. The order for seclusion must be rewritten at regular intervals and the basis for continued seclusion documented in the patient's chart. The patient must be allowed periodic freedom from restraint (if physically restrained) and access to hygiene and toileting facilities. Seclusion must end when the clinical indication for it is over.

In a correctional facility segregation does not have to be based on clinical need, and most often it's not used for mental health reasons. Segregation is usually used for security and disciplinary reasons, in which case it's called "disciplinary lockdown". The length of confinement is predetermined, usually a few days to a few weeks. If the inmate is really really bad (has killed other inmates or correctional officers) or presents an extreme security risk (repeated escapes or organizing riots) the segregation may last for months or even years. Inmates have a lot to lose by being placed in lockdown for this long, so correctional facilities have due process protections in place to provide them with a chance to challenge their confinement. The legal steps used to place an inmate in lockdown are very similar to the process used for civil commitment in free society: the inmate is given a notice that documents the alleged behavior leading to the lockdown, he is given a hearing before an independent factfinder with a chance to present evidence and confront witnesses, and he's given an opportunity to appeal the results of the disciplinary hearing. He is also allowed to be given less restrictive sanctions, like loss of privileges or cell restriction in general population. If all else fails, the inmate has the right to appeal the administrative hearing officer's decision to a court in free society.

So, now that you have this background I'll come to the real reason I want to talk about longterm segregation:

Inmate advocates allege that longterm segregation drives prisoners crazy. Whether you know it or not, millions of taxpayer dollars are spent every year litigating the use of longterm segregation. Specialized correctional facilities, known as control unit prisons, were invented specifically for inmates who require segregation for months or years. Class action suits filed by the American Civil Liberties Union and other advocacy organizations allege that this causes psychiatric deterioration and psychosis, with some groups calling for closure of all control unit prisons.

But is this true?

The fact of the matter is that despite all the money we've spent regulating the use of control unit prisons and monitoring inmates who are on segregation, the data are sketchy. Epidemiologic studies have shown that the prevalence of psychiatric disorders among prisoners increases with each increase in security level---in other words you find more psychiatric patients in maximum security than in minimum security---but this does not prove that high security causes psychiatric disorder. In all likelihood, inmates with aggressive or disruptive behavior, such as those found in maximum security, are more likely to be diagnosed with a psychiatric illness. Aggressive antisocial or borderline inmates often are also concurrently diagnosed with bipolar disorder. Conversely, inmates with psychiatric disorders are less likely to be classified to lower security levels where on-site psychiatry services may not be available. The epidemiologic findings are an artifact of the classification process and a reflection of our limited diagnostic schema.

I did a PubMed search (I'm big on these lately for some reason) using the terms "administrative segregation", "longterm segregation", "control unit prison" and "solitary confinement". There are only about 20 significant articles on this topic going back 45 years---not exactly an overwhelming body of literature. Only four of the nineteen are controlled studies with data, while the majority are descriptive, theoretical or speculative in nature.

Contrast this with the court's view of the psychological effects of control unit prisons, as outlined in David Fahti's law review article "The Common Law of Supermax Litigation" (Pace Law Review Vol. 24:675, 2005):

"Federal courts continue to recognize as established fact that isolated confinement inflicts serious psychological harm on many prisoners."

And in one case cited in the article:

"The effect of prolonged isolation on inmates has been repeatedly confirmed in medical and scientific studies".

The medical articles cited in these legal cases are few, and are usually 20 years or more out of date. They point to the effects of social isolation and sensory deprivation, a line of research popular in the 1960's when research into brainwashing was de rigueur for psychologists. Unfortunately, because most of these cases are settled by consent decree and rarely go to trial, this lack of scientific scrutiny is left unchallenged. The result is that courts are mandating that certain inmates be removed from segregation based on the presence or abscence of an Axis I DSM diagnosis, disregarding the inmate's behavior and adjustment in previous facilities. In one case a court mandated that any inmate with a "serious personality disorder" be removed from a control unit prison---I imagine that must have pretty much emptied out the place.

I agree with the courts that control unit prisons should practice humane care under safe and reasonably comfortable conditions. It should be done because it's the right thing to do but you shouldn't misrepresent or distort scientific evidence to justify it.


I had trouble saving the link to the combined search, so I'll just post the references:
1: Arrigo BA, Bullock JL.
The Psychological Effects of Solitary Confinement on Prisoners in Supermax Units:
Reviewing What We Know and Recommending What Should Change.
Int J Offender Ther Comp Criminol. 2007 Nov 19. [Epub ahead of print]
PMID: 18025074 [PubMed - as supplied by publisher]

2: Cloyes KG.
Prisoners signify: a political discourse analysis of mental illness in a prison
control unit.
Nurs Inq. 2007 Sep;14(3):202-11.
PMID: 17718746 [PubMed - indexed for MEDLINE]

3: Doncliff B.
Solitary confinement in mental health nursing.
Qld Nurse. 2007 Jun;26(3):7. No abstract available.
PMID: 17624037 [PubMed - indexed for MEDLINE]

4: Way BB, Sawyer DA, Barboza S, Nash R.
Inmate suicide and time spent in special disciplinary housing in New York State
Psychiatr Serv. 2007 Apr;58(4):558-60.
PMID: 17412861 [PubMed - indexed for MEDLINE]

5: Andersen HS.
Mental health in prison populations. A review--with special emphasis on a study
of Danish prisoners on remand.
Acta Psychiatr Scand Suppl. 2004;(424):5-59. Review.
PMID: 15447785 [PubMed - indexed for MEDLINE]

6: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R.
A longitudinal study of prisoners on remand: repeated measures of psychopathology
in the initial phase of solitary versus nonsolitary confinement.
Int J Law Psychiatry. 2003 Mar-Apr;26(2):165-77. No abstract available.
PMID: 12581753 [PubMed - indexed for MEDLINE]

7: Andersen HS, Sestoft D, Lillebaek T.
Ganser syndrome after solitary confinement in prison: a short review and a case
Nord J Psychiatry. 2001;55(3):199-201.
PMID: 11827615 [PubMed - indexed for MEDLINE]

8: Andersen HS, Sestoft D, Lillebaek T, Gabrielsen G, Hemmingsen R, Kramp P.
A longitudinal study of prisoners on remand: psychiatric prevalence, incidence
and psychopathology in solitary vs. non-solitary confinement.
Acta Psychiatr Scand. 2000 Jul;102(1):19-25.
PMID: 10892605 [PubMed - indexed for MEDLINE]

9: Gore SM.
Suicide in prisons. Reflection of the communities served, or exacerbated risk?
Br J Psychiatry. 1999 Jul;175:50-5.
PMID: 10621768 [PubMed - indexed for MEDLINE]

10: Sestoft DM, Andersen HS, Lillebaek T, Gabrielsen G.
Impact of solitary confinement on hospitalization among Danish prisoners in
Int J Law Psychiatry. 1998 Winter;21(1):99-108. No abstract available.
PMID: 9526719 [PubMed - indexed for MEDLINE]

11: Farrell GA, Dares G.
Seclusion or solitary confinement: therapeutic or punitive treatment?
Aust N Z J Ment Health Nurs. 1996 Dec;5(4):171-9. Review.
PMID: 9079314 [PubMed - indexed for MEDLINE]

12: Grassian S, Friedman N.
Effects of sensory deprivation in psychiatric seclusion and solitary confinement.
Int J Law Psychiatry. 1986;8(1):49-65. No abstract available.
PMID: 3940165 [PubMed - indexed for MEDLINE]

13: Suedfeld P.
Measuring the effects of solitary confinement.
Am J Psychiatry. 1984 Oct;141(10):1306-8. No abstract available.
PMID: 6486277 [PubMed - indexed for MEDLINE]

14: Grassian S.
Psychopathological effects of solitary confinement.
Am J Psychiatry. 1983 Nov;140(11):1450-4.
PMID: 6624990 [PubMed - indexed for MEDLINE]

15: Volkart R, Rothenfluh T, Kobelt W, Dittrich A, Ernst K.
[Solitary confinement as risk factor for psychiatric hospitalization]
Psychiatr Clin (Basel). 1983;16(5-6):365-77. German.
PMID: 6647886 [PubMed - indexed for MEDLINE]

16: Kaufman E.
The violation of psychiatric standards of care in prisons.
Am J Psychiatry. 1980 May;137(5):566-70.
PMID: 7369400 [PubMed - indexed for MEDLINE]

17: Maclay DT.
Letter: Solitary confinement in control units.
Lancet. 1975 Aug 30;2(7931):408. No abstract available.
PMID: 51211 [PubMed - indexed for MEDLINE]

18: Gendreau P, Freedman NL, Wilde GJ, Scott GD.
Changes in EEG alpha frequency and evoked response latency during solitary
J Abnorm Psychol. 1972 Feb;79(1):54-9. No abstract available.
PMID: 5060981 [PubMed - indexed for MEDLINE]

Effect of solitary confinement on prisoners.
Am J Psychiatry. 1963 Feb;119:771-3. No abstract available.
PMID: 13998703 [PubMed - indexed for MEDLINE]

Fluctuations in level of consciousness caused by reduced sensorial stimulation
and by limited motility in solitary confinement.
Psychiatr Neurol Neurochir. 1962 Nov-Dec;65:377-401. No abstract available.
PMID: 14002046 [PubMed - indexed for MEDLINE]


Lee said...

In my first psych hospitalization I spent 24 hours-ish in the psych ER waiting for a bed in the real hospital part. I was in a room by myself. All my stuff was taken away so I had no new stimulation. I could go down the hallway to shower and go to the bathroom but they got mad if you talked with any of the people in the neighboring rooms. So all I had was a couple of brief doctor visits and nurses stepping in to take vitals.
This wasn't due to any specific clinical reason, they did this for everyone in the Psych ER there.
I hadn't come in in very good shape obviously. But after a day of that I was definitely a lot crazier that I'd been when I'd come in.

The others I've been to since have been better because they have had someone 'babysitting' me who I could talk to.

Anonymous said...

Segregation can be used for a lot of reasons but treatment isn't one of them. Mentally ill inmates are often kept there for their own protection but it is not a healthy environment by any means. Unfortunately, there's usually no place else for them.

Anonymous said...


This boggles my mind that they do this to people who were in your situation. I would love for the staff who do this to be in the same situation. Let's see how they like it.
Boy, that makes me so mad and I was never in your situation fortunately.

Geez, I went crazy waiting in regular ER for a relative to be taken to a regular hospital room. I thought 8 hours was insanity.

Clink, you might be familiar with this story,, about a patient who was held in seclusion in Virginia Western State Hospital for 20 years.

The feds told the hospital in 99 to change his treatment but nothing was done. Now, the oversight committee has ruled his rights were violated.

Interestingly, the hospital felt it was safe to allow the patient and the family out of hospital visits to places like Walmart.

Totally mind boggling.


Anonymous said...

Romeo: In the facilities I've worked in, when mental health put someone in segregation is was done voluntarily with the informed consent of the inmate. Usually it was because the inmate was upset and needed to stay in a private place where he could cry away from other inmates, sometimes it was to protect a vulnerable inmate. I think it can be therapeutic to have a relatively safe, protected environment for some people.

Anonymous: Fascinating case. I'd love to know more details separate from what's presented in the media. Presumably the patient would go back into the seclusion room voluntarily after returning from the family day pass? Was it a locked seclusion room? Was it just another way of giving a patient a single room? I'm sure there's more to this than meets the eye.

Anonymous said...

No, it wasn't and isn't voluntary, no it is not a way of giving a patient a single room (were you jokoing?). The full opinion of the human rights committee is on my blog, not the media account, read that one if you don't trust the newspaper accounts for some reason, maybe i'ts hard for you to accept that psychiatrists can do bad things to patients? You might want to work on that issue.

Anonymous said...

Hymes: No I wasn't joking and no I don't automatically believe the media's representation of events. You have to admit this is a pretty extreme case that would raise questions about the total picture.

In correctional facilities we do have inmates who actually want to be in segregation because they really do want to be alone. It's not outside the realm of possibility, particularly if a public facility is crowded and has only public multiple-bed wards.

Obviously I'm not familiar with this case and I'm just speculating. Thanks for the link to the hearing report.

Anonymous said...

If I had the energy I could find the Department of Justice letter to the Governor of Virginia that includes reference to Mr. C./C.C. in the '90's, I have it somewhere but probably in a file or on my old computer and I'm tired. If I find it later I'll post the link. This situation is exactly as the media has represented it sadly. Time for bed for 11% kidney functioned me though.

Dinah said...

This was incredibly long. YOu had 20 references for a blog post//??? This is supposed to be FUN, not "writing term papers 101."

Okay, so I had some trouble with the issue of likening Solitary Confinement to Hospital Seclusion.

In my limited inpatient world from years ago, most of the people in seclusion were very agitated, disruptive, dangerous, and as soon as they chilled, they came out, even if it meant having them with a one-on-one sitter to keep them safe. It's an extreme measure, usually seemed necessary to keep everyone safe.

Solitary Confinement inside your walls--- well, as punishment, it's just not the same, and even by- request for the prisoners safety, it's a different phenomena from psychiatric seclusion.

I would go nuts, I'm sure of it.
And Roy...can you imagine Roy going more than an hour unplugged from his devices. He'd get worse, I'm sure.

ClinkShrink said...

It really isn't all that different from psychiatric seclusion except for the length of time for some guys.

It's over a 1000 words because it's a topic that's been nagging at the back of my mind for a while. I started writing and it just happened, what can I say? I figured I'd need to include the references or no one would believe me how scant the data actually are.

The guys who go into control unit prisons are difficult and dangerous, and they require two-to-one or sometimes even four-to-one sitters (officers) to keep them safe when they come out, which is why I get concerned when a judge orders that they be moved out of solitary just because they've been given an Axis I diagnosis, based on grossly incomplete research findings. I thought that was a pretty important and bloggable topic.

Yeah, it's long. Kudos to you and anyone else who made it through the whole thing.

Zoe Brain said...

Give me a selection of books, or better, a web connection, and I'd be as happy as larry in solitary for days or even months. Even if I didn't see another human being.

But take away all stimulation, and I'd go very psychotic very quickly.

Lee said...

Anonymous: What's crazier is that it happened at what' supposed to e a top hospital, new york presbyterian.
When I got to the normal hospital part all the staff I spoke with about it acknowledged that the psych ER has problems but that doesn't fix it.

Anonymous said...

Lee, can't say I am surprised at all. Sorry for being so cynical.

Clink, there alots of cases of abuse or that don't even make the media. Hymes reported on her blog about someone who was tasered at a local psychiatric hospital that wasn't reported by the media.

I also did volunteer work on a case in which I couldn't even get the alternative media to cover.

The fact that an organization like the Richmond Times covered this Western State Hospital Case means it is pretty outrageous.

And with all due respect, I think Hymes raises a good point about psychiatrists and actually doctors in generally not wanting to accept that other doctors do bad things to patients.

Several years ago, there was a story about a local psychiatrist that did make the paper who committed such horrific malpractice that a mom died and the kids were scarred for life. But what struck me in the article was that so many doctors knew what was going on and said nothing. They feared if they spoke out that they would suffer professional retaliation.

Also, here is a link from Hymes site that points out the dangers in thinking there is always a side to every story:

According to patients at ASH, the incident (murder) could have been avoided if their complaints about McKee hadn't been ignored.

Patient John Parrish says he has complained about McKee before.

"We all did - we told staff that this man is going to get violent and he's going to hurt somebody. We knew. We knew. They knew," said Parrish.

Sorry for getting off topic but I felt you made some points that needed to be addressed.


Awake and Dreaming said...

I worked with an awesome psychiatrist who told me that he hoped in 30 years people thought what he did was barbaric. He acknowledged that Doctors do bad things. He acknowledged that he probably does bad things, and that hopefully in 30 years treatments will be so much better, that this will look like hell. Which is perhaps what it is for people.

I can't even begin to imagine solitary confinement. I can't even stand spending 24 hours alone in my house with the internet, phone, dvd player etc...

My sister inpatient at child/adolescent psych right now and when i took her on a pass she told me about the "quiet room" that comes complete with physical and chemical restraints, and how it petrified her. One of her friends on the ward was put in there and my sister freaked. And now she's so scared that if she lets her feelings out, she'll wind up out of control and in there too. It's interesting.

ClinkShrink said...

Anon: I know exactly what you mean about the media being selective about the events they cover. After several years working in public facilities I know that events happen which never draw public (or media) attention, and I've also seen media reports of events that have no resemblance to what actually occurred. It slants both ways. Thus, when it comes to news reports I maintain an open mind (call it skepticism if you will), ask a lot of questions and consider the information I get in return.

Zoe: You raise a good point. Reaction to confinement is shaped by personality and personal interests. I once did an informal poll of forensic patients at our local hospital. Of all the patients who had experienced both prison and hospital, the results were divided when I asked them which type of facility they'd rather be in. The patient who were introverted or had negative symptoms preferred prison, where they wouldn't be required to participate in groups or occupational therapy. The extroverts and manic patients preferred hospitals because they COULD participate in things. It was interesting, and it was a good reminder to me that you can't make assumptions about the quality or nature of an experience based on one's own preferences.

CanadaHolly said...

I'd like to step in here and defend the 20 references at the end. One of the beauties of the Internet is that you can lard in all this supplementary material for future reference, without taking up any extra space or tiring anyone out -- a list of references like it is easy to skip over until wanted later.

As far as solitary confinement, I was very glad to read this posting. But also extremely surprised that there is so little research on the topic, considering how common the practice is. Obviously, prison authorities know that solitary confinement is painful, or they wouldn't use it or find it effective as a punishment.

Do you think it might help to look for research using search terms like isolation, loneliness, reclusive, and similar things? I know that there are people who seek out isolation or who are very comfortable in the absence of other people -- however, I don't know if this effect would persist if the isolation was being enforced by other people that we patient sees as being indifferent or hostile to their well-being.

ClinkShrink said...

Mrs. Cake: Thank you for your thoughtful comment. Back in the dark ages I spent quite a bit of time researching the topic for a chapter I was writing. Real life intruded, the chapter never got written, but I still have the draft and I refer back to it periodically. In addition to the search I did for this blog post (and it's interesting to see only a few more studies have been done in the last five years on this topic), in the past I included search terms related to social isolation, sensory deprivation and others. The results are pretty much the same.

Roy said...

Soon you'll have fellows and residents. One of them will surely show an interest in helping you finish off that chapter.

Anonymous said...

Just came across this thread - I'm a prosecutor and currently have a case with a prison inmate who is representing himself as to a charge of assaulting prison staff. I Googled "SHU syndrome", the acronym for the defense he is attempting to pursue, and found these postings.

Wondering whether there is any additional research that has been done in the past years?

ClinkShrink said...

Yes, there's been something new published. It's the best (only) controlled study of the effects of longterm segregation. I reviewed it here:

I also wrote a column about the dilemma of teasing out serious mental illness (for the purpose of barring transfer to solitary) from serious personality pathology here: