Solitary Nation

Solitary confinement has been trending as a topic of debate in recent years. In 2013, Tom Clements, executive director of the Colorado Department of Corrections was shot and killed at his house near Colorado Springs. Clements was well known as a reformer set to improve mental health services to inmates and to reduce the use of solitary confinement in prison. According to the Denver Post, since Clements’ arrival in 2011, the number of inmates in solitary confinement had been cut in half. In a tragic irony, Evan Spencer Ebel, the parolee who killed Clements, spent much of his eight-year stint in prison in solitary confinement.

One important consideration, says Bill Sessa, information officer at the California Department of Corrections and Rehabilitation (CDCR), is how the term solitary confinement is used. The term “implies much more than any practice we previously had in place.”  There is a connotation to the term that people, especially pundits, use loosely referring to what is generally known as “the hole,” a practice CDCR does not use. Says Sessa, “It implies that a person is put in a cell by themselves and ignored as punishment.” It’s a term that can be misleading. “In most cases, when critics contend we practice solitary confinement, they refer to the former practice of segregating gang leaders from the rest of the inmate population. For many years, we had a segregated housing unit in Pelican Bay for that purpose. It was created to protect the safety of the prisons and the general inmate population and staff. All of the inmates housed there were confirmed as gang members, many of them leaders of gang activity.  Even though they were housed separately from the general inmate population, they had regular contact with prison staff, although they were confined to their cells in that unit and did not have the same freedom to move about the prison as other inmates.”

The unit at Pelican Bay is currently being converted into general population housing. CDCR does segregate inmates in Administrative Segregation, which is essentially a jail within the prison.  Inmates are housed in single-cell units but have continuous access to officers and other staff. Neither of these practices is the equivalent of being placed in “the hole.” The Administrative Segregation unit provides that same access and regular contact with staff and the amount of time an inmate spends in that unit is determined by the outcome of hearings internally at the prison or by the amount of time it takes a county D.A. to file more serious charges that would put the inmate in front of a judge for trial. For purposes of uniformity here, solitary confinement refers to the World Health Organization’s definition: “The physical and social isolation of an individual in a single cell for 22.5 to 24 hours a day, with the remaining time typically spent exercising in a barren yard or cage.”
The Effects of Solitary
Joel Andrade, Ph.D., LICSW, CCHP-MH, director of Clinical Operations, Mental Health, MHM Services, Inc. and John Wilson, PhD, CCHP-MH, vice president of Clinical Development at MHM Services note, “The effects of solitary confinement on an inmate are significant and wide ranging.  Effects range from medical problems to mental health problems including suicide.” They point out that it’s not a matter that can easily be studied, though. Research in this area is limited because randomized controlled studies are restricted by the ethical issues surrounding it. Clinicians, correctional mental health experts, and researchers have reached a range of conclusions about the impact of solitary confinement, though, which range from an innocuous "it’s not helpful" to the UN's Mandela Rules, which concluded that solitary confinement constitutes torture. “The conditions of confinement vary greatly from one solitary confinement unit to another. These conditions can make a stay in solitary confinement more onerous. For example, deprivation of reading materials can increase the intensity of the inmates' isolation.”
Medical Issues
From a medical standpoint, according to WHO, corrections personnel should take into consideration the effects of solitary confinement can be wide ranging. There are three main factors inherent in all solitary confinement: social isolation, reduced activity, and loss of autonomy and control over almost all aspects of daily life. Lack of the ability to exercise can lead to some medical complications such as gastrointestinal problems, genitourinary problems, back and joint pain, weight loss, diarrhea, diaphoresis, insomnia, deterioration of eyesight, profound fatigue, heart palpitations, migraines, and aggravation of pre-existing medical problems.

Ronald Smith, Psy.D., CCHP-MH, corporate director, Behavioral Health Services at Wexford Health also notes that for inmates placed in solitary, there must be “continual and routine medical assessment, along with routine mental health assessment and appropriate follow up.” As noted by WHO, it has been well-established that solitary confinement constitutes an important stressor and risk of suicide. Says Smith, “Doctors must pay particular attention to such prisoners and visit them regularly of their own initiative, as soon as possible after an isolation order has taken effect and daily thereafter to assess their physical and mental state and determine any deterioration in their well-being.”

Potential Mental Health Issues

A question that often arises is if solitary confinement can initiate mental health issues. According to the National Commission on Correctional Health Care (NCCHC), mental health effects in solitary confinement are equally wide ranging and can include deterioration of mental health including anxiety, depression, anger, diminished impulse control, paranoia, obsessive thoughts, decimation of life skills, social alienation, cognitive disturbances, visual hallucination, auditory hallucinations, hypersensitivity to stimuli, PTSD, psychosis, self-injury and suicide. (They recommend that “Juveniles, mentally ill individuals and pregnant women should be excluded from solitary confinement of any duration.”)

Smith notes that virtually all reviews of the practice of solitary confinement conclude that maintaining an individual under these conditions, particularly for more than 10 days, results in harmful emotional, cognitive, social and physical effects. Individuals without mental health issues may experience a number of symptoms when placed in solitary confinement or segregated housing units.  It is because these conditions cause extreme mental and emotional distress which, in some cases, can lead to a diagnosable mental illness.
Inmates Who Have A Serious Mental Illness
Over the past few decades, the role Corrections has had on addressing mental health has changed dramatically. Correctional facilities have become the de facto mental health care providers, a phenomenon that has required a significant amount of adjustment for personnel who had not anticipated playing a role in health care. Andrade and Wilson explain, “No inmate with a Serious Mental Illness (SMI) should be placed in segregation for any significant period of time (i.e, days).” They further that these individuals should be placed in units designed as alternatives to segregation. “In general, the number of inmates in solitary confinement (including those without pre-existing mental health issues or SMI) should be significantly reduced.

On any given day, approximately 4%-5% of the total state and federal prison system is in solitary confinement, and over 12 months approximately 18% are placed in segregation at some time. This significant deprivation should be reserved by correctional departments for only the most significant of issues and for very short periods of time.” They further that facilities and departments that have alternative units for SMI individuals and find alternative sanctions for all inmates (SMI and not SMI) will find their facilities are generally safer and their employees experience greater job satisfaction.

According to Smith, individuals with mental illness are more likely to be confined to segregation because they have greater difficulty in controlling their emotions and as a result often miss social and verbal cues. Segregation can increase symptoms of an inmate’s mental health disorder when placed in solitary.

“It is essential that when an offender has been placed in segregation, a qualified health care professional reviews the offender’s health record to determine if his or her needs contraindicate the placement or require accommodation.” He furthers that this is particularly important in the case of mentally ill offenders because they are likely to stay in segregation for a longer period of time than those without mental health issues. As a result of their increased stress levels and limited ability to follow instructions, mentally ill offenders have difficulty acting in ways that would otherwise keep them free from committing infractions.
Smith furthers that the primary concerns with solitary confinement are the length of time spent in confinement, the number of hours spent out of cell during the confinement period, and most importantly, “The offender needs a means by which they can work toward release.” Indefinite or long term confinement will have the most detrimental effects on an individual. It is important to allow the offender to have opportunities to participate in clinical programming aimed at reducing the effects of social isolation, increasing behavioral control, and that allows them to shorten their confinement period.

Since mentally ill offenders are placed in solitary at about three times the rate of those without mental illness, Wexford Health developed a comprehensive evidence-based in-cell program providing offenders with the structure and methods to systematically work their way out of segregation. “Planned and regular programming is a fundamental underpinning of this program. The offender learns to take control over planning their day and learning activities. An important objective is to reduce the likelihood of decompensation or suicidality,” says Smith.
Social interaction is a basic human necessity and is vital for the stability and “mental hygiene” of an individual, he adds. “Offenders are no different and require social contact on a routine and predictable basis. Typically, offenders who are isolated from social contacts will experience symptoms of depression and/or anxiety and agitation. The experience of symptoms of mental illness is correlated not just to the isolation itself. It is also in relation to the length of time one is isolated as well as the individual’s ability to be reintegrated back to a less restrictive housing unit.  In other words, does the inmate retain hope?”