As politically popular "supermax" prisons and extended solitary confinement have become widespread in the United States in recent decades, mental health advocates, including psychiatrists, have begun to push back because of concerns about the mental health sequelae of this type of incarceration. However, divisions remain among psychiatrists over whether extended solitary confinement causes mental illness and how best to reform such prison practices.
At the center of the debate are state-run supermax prisons, which have grown to house at least 25,000 prisoners nationally. These facilities hold the most violent inmates. Typically prisoners are kept alone in small cells for 23 hours a day, plus an hour of solo recreation in a caged area. Meals are delivered through a slot in a solid door, and radios and TVs are not allowed. Supermax units within some prisons operate in a similar manner.
Similar focus has fallen on those placed in solitary confinement for breaking prison rules. For instance, the federal system has 11,000 prisoners in such "special housing units," according to the Bureau of Prisons, and thousands more are in solitary confinement in state prisons and county jails.
The extensive use of solitary confinement has drawn growing criticism from mental health advocates. That's because prisoners with mental illness are often relegated to this type of detainment when they fail to follow rules, which they may be unable to do because of their illness.
Although there has been no comprehensive examination of all supermax or other solitary-confinement populations, some research indicates that the prevalence of psychiatric illness among supermax inmates can reach over 50 percent, said forensic psychiatrist Paul Appelbaum, M.D., a member and former chair of APA's Council on Psychiatry and Law and a past APA president.
"The data are not very good," he commented. "However, it doesn't take a lot of evidence to see it's not good for people with serious mental illness."
Stuart Grassian, M.D., a Massachusetts psychiatrist in private practice, has studied inmates housed in solitary confinement and served as an expert witness on its effects. He said that many such inmates have suffered either "severe exacerbation or recurrence of preexisting illness," or they were previously mentally healthy but had an onset of acute mental illness while in solitary confinement. The signature feature of supermax prisons and solitary confinement, the lack of external stimulation through human contact and audio or visual devices, is at the root of its impact on mental health.
"The people most likely to do the worst in solitary confinement are those who are cognitively impaired," Grassian told Psychiatric News. "The cognitively strong do the best because they generate their own ideas from the inside."
He believes that extended solitary confinement is likely to induce either obsessive behavior or delirium. The obsessive behavior may be channeled into positive activities in mentally healthy prisoners, but people with mental illness can become obsessed with negative actions, such as self-mutilation. Prisoners suffering delirium while in solitary are left hyper-responsive to external stimulation after they are released, and some develop conditions such as posttraumatic stress disorder, he noted.
"Without an adequate level of external stimulation, many will have a reduction in their functioning," Grassian said.
The issue of extended solitary confinement recently arose in Maine, where law-makers considered legislation earlier this year that would have limited solitary confinement to 45 days and banned its use for prisoners with serious mental illness. The legislation (LD 1611) was championed by the Maine Association of Psychiatric Physicians, whose past president, Janis Petzel, M.D., testified on its behalf. It also was backed by a coalition of civil-liberties, religious, and human-rights groups. The bill targeted the Special Management Unit of the state maximum-security prison, where more than half the inmates are classified as seriously mentally ill.
The bill was voted down on April 6, however, after the Department of Corrections opposed it, maintaining that barring the use of solitary confinement would endanger the safety of guards and other prisoners. However, the legislature opted to approve a study of solitary confinement that could lead to recommendations for future legislative changes to the practice.
Jeffrey Metzner, M.D.: There is no evidence that extended solitary confinement causes mental illness, but for those who have a mental illness, it exacerbates the situation.
Psychiatrist advocates for prisoners with mental illness, such as Jeffrey Metzner, M.D., former chair of the APA Committee on Judicial Action, said Maine's study of the problem and search for improvements was a step in the right direction, but cautioned that the study should include experts not employed by the state prison system.
Maine was the latest state to address mental health issues involved in extended solitary confinement. Other states have modified their use of solitary imprisonment, mainly as a result of lawsuits. Those modifications have ranged from changes described by Grassian as "bizarre" in California to ones widely praised, such as those in New York.
A lawsuit on behalf of prisoners with mental illness in California's Pelican Bay supermax prison produced less than ideal results. In that case, after a court disallowed the use of solitary confinement for people with mental illness, prison officials simply redesignated part of the prison as a "mental health unit." Prison officials then instituted an hour a day of "psycho-educational teaching" for the prisoners, who were placed in cage-like outdoor cells arranged in a semicircle and facing a counselor.
"It was so ludicrous," said Grassian, who witnessed a similar exercise at another prison. "But if nothing else, it does get these guys out of their prison cells for an hour every day, which is great."
The New York changes, however, most importantly included updating the training and practices of the state's prison system so that guards are taught the signs and symptoms of mental illness and prison officials are required to provide treatment to patients with mental illness instead of punishing them through solitary confinement.
"Both prisoners and guards were pleased with the outcome of those changes," Grassian said.
The limited range of outcomes for court-ordered interventions in prisons that use extended solitary confinement leads some psychiatrists to see the possibility for more comprehensive changes through legislation.
Henry Weinstein, M.D., chair of the APA Caucus on Correctional Psychiatry and a clinical professor of psychiatry at New York University, said that legislation could help coordinate the different groups of professionals in prison systems—including guards and mental health professionals—to prevent sending people with mental illness to solitary confinement. However, in cases in which solitary confinement is extensively used by prison staff in an attempt to deal with people with psychiatric conditions, lawsuits are needed to remedy the practice.
"Security concerns should not put them in [solitary confinement] for displaying mental illness symptoms when what they need is care," Weinstein told Psychiatric News.
Prison reforms, countered Grassian, are most likely to be realized when they come through lawsuits. Court orders are the only drivers of change that are powerful enough to overcome not only hesitancy of prison officials to make changes they view as security-related but also to require state governments to provide the funding needed to implement intensive mental health treatment options for people with mental illness. Otherwise, such politically unpopular funding is often among the first budget items cut in tight fiscal environments, he said.
Another issue on which psychiatrists sometimes differ is whether solitary confinement actually causes mental illness in previously healthy inmates or if its effects are limited to the exacerbation of preexisting illness.
Metzner, a forensic psychiatrist and author of "Solitary Confinement and Mental Illness in U.S. Prisons: A Challenge for Medical Ethics," published in the Journal of the American Academy of Psychiatry and the Law, said there is no evidence that extended solitary confinement causes mental illness, but for those who have a mental illness, it exacerbates the situation.
"If you have a serious mental illness in a supermax prison, you don't get better, and sometimes you get worse," Metzner told Psychiatric News.
But some psychiatrists see the harsh isolation of solitary confinement as likely to cause mental illness in previously healthy inmates.
Terry Kupers, M.D.: People with no previous history of mental illness can become ill in extended solitary confinement, which he defines as longer than three months.
Terry Kupers, M.D., a psychiatrist who has studied supermax prison populations and testified in lawsuits over their treatment, said people with no previous history of mental illness can become ill in extended solitary confinement, which he defines as longer than three months.
"Especially people with earlier traumatic episodes, who are also more likely to self-medicate by abusing drugs, be arrested, and be attacked while in prison, which lands them in solitary confinement [as punishment]," Kupers told Psychiatric News.
Weinstein believes that solitary confinement can have mental health impacts on both healthy people and those with psychiatric illness. Its effects are likely similar to the mental health consequences of torture, which leave some permanently mentally impaired and others relatively unscathed.
Ultimately, Weinstein said, the best strategies for avoiding mental illness among prisoners in solitary confinement and for reforming systems that use extensive isolation of prisoners will require more research to better quantify the occurrence of illness and what lessens its occurrence.
The Maine legislation on extended solitary confinement can be accessed at <www.maine.gov/legis/> by searching on the bill number, LD 1611.