Douglas A. Kramer, MD, MS

Johan left this world exactly as he lived, with grace, honor, integrity, humor, love, humility, intellect, and a continuing interest in our ongoing professional conversations. Dr Verhulst was a member of the 

In the last months of Johan’s beautiful life, he engaged Ronald Pies, MD, Editor in Chief Emeritus of 

on dignity and autonomy at the end of life, physician assisted suicide, and the role of physicians with respect to the “self determination of another person.”

, “The autonomy-limiting effect of the medical control is a reality, which cannot be negated by ethical intentions or by the unshakable, yet totally unsubstantiated belief that-in the absence of manifest pathology-physicians are capable of distinguishing between a healthy and an unhealthy desire to control the end of one’s life.”

Johan also co-authored a final publication, with contributions from his wife, Dr Julia Heiman, a thoughtful article on undecidable human dilemmas, published 

 Co-authored by fellow GAP Research Committee member, John Beahrs, MD, they begin, “The parties to such dilemmas often share a common ambivalence about the issue but gravitate to opposite poles; then they come into conflict and become increasingly polarized-at each other’s throats over what they actually share.” The authors conclude, “In all such cases, the parties had possessed common interest with shared ambivalence, selectively swung to opposite poles through binary thinking, and came into unnecessary but increasingly intractable conflict. Perhaps validating the nature of undecidable choices and shared ambivalence can offer more hope for human reconciliation.”

Johan had an incredible life and an equally incredible career. He was born in Leuven, Belgium, in 1938. Medical school and a master’s in psychology were at 

. Residency in psychiatry began at the University of Leuven and was completed at the University of Utrecht in Holland. Psychoanalytic training with training analysis was at the Amsterdam Psychoanalytic Institute, and training in group psychotherapy was with the Dutch Society for Group and Family Therapy. His training analysis was with S. J. R. de Monchy, MD,

 who in turn had been analyzed by Freud (twice).

Johan was a visiting professor at the University of Washington in Seattle, both in 1971 and 1977. Following the second visiting professorship, he remained there for the duration of his career. He was a beloved and highly recognized Training Director at the University of Washington for 12 years, receiving the Faculty Teaching Award three times (1986, 1992, and 1996), and the Gary Tucker Career Education Award in 2006. Dr Tucker was a mentor, colleague, and friend. They collaborated on two articles, “Medical and narrative approaches in psychiatry,”

 and later, “How many psychiatrists do we need?”

 The photo is with his friend, colleague in the residency training program, and former GAP Research Committee member, Dr Cornelius (Cor) Bakker.

At the GAP Research Committee meeting two years ago, I mentioned the “best psychiatrist in Madison (WI).” With a twinkle in his eye, Johan asked, “Who might that be?” The answer: Art Walaszek, coincidentally the Training Director for 15 years (and continuing) at the University of Wisconsin. Johan responded-proudly but understated, “Dr Walaszek trained with us.” I should have known.

Dr Verhulst’s first publication, “Compensation neurosis and pseudo-identity,”

. The first of nine publications with his spouse, Dr Julia Heiman, Director of 

 (2014), “An interactional approach to sexual dysfunctions,” was published in 1979 in the 

 Their final joint publication was in 2003, “Childhood sexuality and adult sexual relationships: How are they connected by data and by theory?”

The social brain: A unifying foundation for psychiatry

Perhaps the culmination of Dr Verhulst’s intellectual career has been the “social brain” concept with relevance to psychiatry. Dr Verhulst was the leader of the GAP Research Committee project on the social brain that resulted in multiple publications. An initial brief description, “

 A full article, “The social brain in clinical practice,” followed in 2005.

 In the latter, the authors proposed, “that seeing psychiatry’s core organ as the ‘social brain’ refines and extends the basic science of psychiatry.” In the “unifying foundation” article, the authors assert:

The social brain is defined by its function-namely, the brain is a body organ that mediates social interactions while also serving as the repository of those interactions. The concept focuses on the interface between brain physiology and the individual’s environment . . . Brains, including human brains, derive from ancient adaptations to diverse environments and are themselves repositories of phylogenetic adaptations. In addition, individual experiences shape the brain through epigenesis; that is, the expression of genes is shaped by environmental influences. Thus, the social brain is also a repository of individual development . . . The social brain concept allows psychiatry to utilize pathogenesis in a manner parallel to practice in other specialties.

These two GAP Research Committee articles introduced the term “social brain” to the psychiatric/medical/psychological literature. The only prior reference to the “social brain” was (appropriately) in the anthropology literature where the idea was described by Robin I. M. Dunbar, a British anthropologist and evolutionary psychologist, in 1998.

 Although not using the term “social brain,” nor focusing on the relevance to psychiatry, the most pre-eminent neuroscientist of the 20th century, in my opinion, and Johan’s, Walter J. Freeman, MD, proposed a similar idea in his book, 

 “The most important function of brains is to interact with each other to form families and societies . . . meaning arises in social relations (page 1).”

 The accompanying photograph shows Dr Freeman and Dr Verhulst talking during a break at the GAP Research Committee meeting – Spring 2012.

Thus, all subsequent reference to the social brain concept in the psychiatric literature derives from the work of Johan Verhulst and colleagues of the GAP Research Committee. For example, “An organ system for a social organ must, by definition, include other social organs (ie, other brains). One brain cannot evolve in isolation from other brains. Social organs, by necessity, interact just as fluidly as the liver and pancreas or the heart and lungs. The science of the last 25 years is consistent with the philosophies of Ackerman, Bateson, and Whitaker. The 

 (PSOS) is thus the organ system of interest to psychiatrists.”

Eight days before Johan departed, he sent colleagues a two page “theoretical framework” because he believed an update on the social brain concept was needed. I want to emphasize 

 possessed by our friend. Here is the first paragraph (copies available upon request):

The social brain consists of structures and processes in the nervous system that incorporate embodied interactional knowledge, which is the result of social learning at different levels. Thus, the social brain includes: (a) the effects of evolutionary learning exemplified in the genetically encoded adaptations to living in social groups, subject to epigenetic changes, (b) the effects of basic developmental learning in early childhood through engagement in specific interaction patterns that help form a first sense of self, others, and interpersonal context, and (c) the effects of socio-cultural learning through on-going discourse in the family, society, and the broader culture; through these interactions one acquires schemas of one’s social role and that of others in various contexts; these schemas further develop one’s sense of self and may be modified with new interpersonal experiences.

Johan was particularly proud of an award he received in 1978, the 

 (Cross of Knight in the Order of the Crown), awarded by the King of Belgium-perhaps a form of knighthood in Belgium. The award was for his public service (including his military service). His father was awarded the same designation before him. About a year ago, he told me that among other benefits the award provides for is a detachment of the Belgium Army to fire rifles over his gravesite-near his cabin on the Puget Sound.

Two years ago, a small group of colleagues including Johan began sharing jokes and humorous stories, sometimes called “Jumor for Johan.” Johan was an active contributor and had some of the very best stories, and he appreciated the intent. This sharing of humor closed on May 3, 2019. Sometime prior to that day, he told us, 

“I have enjoyed, and am grateful for, the respect and warmth that always infused our interesting conversations. And I am sorry but I plan on taking the best jokes with me into eternity. With friendship and may you survive me in health and happiness, Johan.”

 And Johan did have some of the best! Here is his final contribution to 

 in reply to a mutual friend’s dream on dying that was followed by a joke comparing Heaven and Hell:

Hello my dreaming friend, walking in the clouds as a result of the unbelievably wonderful and touching emails from my friends of the Research Committee, I had decided not answer any of them. After all, keeping an email exchange going carries the risk of getting "on the other hand" messages. However, I cannot do so in your case. I have to respond. To start with, the joke at the end of your email was quite hurtful (it hurts when I laugh!!). Nevertheless, I will secretly pass it on to Mr Peter (that's how he now prefers to be called) at the gates. On the other hand, really disturbing is your email's revelation that the afterlife is just like it is in the here and now. So the bureaucrats have won and conquered the hereafter!!?? I still know that, in reality, my upcoming exit is a well-deserved, personal triumph over the curse of immortality, but now you make me realize that it is but a pyrrhic victory! Thanks a lot, friend! I "cc" Doug, the chair of our committee, as a disciplinary action may be warranted. With deep despair, triggered by the spectre of an eternity of looming electronic medical records, Johan.

Our relationship in this life did not end with bureaucrats, pyrrhic victories, and disciplinary action, which did serve to lessen our sense of an impending loss, but with warm, honest, loving final expressions the following day. My thanks to Dr Julia Heiman and Dr David Keith for significant contributions to this remembrance.

Of the wise men I have known, you’ve been the wisest and the warmest

I will close with what I believed at the time would be my final email to Johan (April 29, 2019), but he insisted on continuing the conversation (as you have seen above), with a few friends, our back-and-forth interweaving of love and humor until May 3rd, six days before his departure.

“Dear Johan, Of the wise men I have known, you’ve been the wisest and the warmest. I know there was a cost, but thank you for hanging out a bit longer than you anticipated. In life and in death, you've had both dignity and integrity. You run circles around most with your intellect, but your humility prevents the awareness. You are a gentle man for the ages. The jokes have been and will be a continuing connection. (On a professional note, your Medical Alliance

 paper will be a beacon for future physicians when the shaman is resurrected.) With enduring friendship, and with my love, may peace be with you always. Doug.”

Douglas A. Kramer, MD, MS
	Middleton, WI
	Chair, Committee on Research
	Group for the Advancement of Psychiatry

Editor's note: This piece was originally published in the Group for the Advancement of Psychiatry Newsletter. It is published here with permission.

Two misleading myths regarding “medical aid in dying.”

2. Verhulst J. Letter to the editor by Johan Verhulst, MD, FACP. 

https://www.psychiatrictimes.com/two-misleading-myths-regarding-medical-aid-dying/page/0/4

3. Verhulst J, Beahrs J. Undecidable choices and the polarization of shared ambivalence: What can psychiatry add to dispute resolution? 

https://www.psychiatrictimes.com/couch-crisis/undecidable-choices-and-polarization-shared-ambivalence-what-can-psychiatry-add-dispute-resolution

4. de Monchy SJR. Rhythmical convergence spasm of the eyes in a case of tumour of the pineal gland. 

5. de Monchy SJR. Adam - Cain - Oedipus. 

6. SzÃ©kely L. Obituary –– S. J. R. de Monchy, 1893-1969. 

7. Verhulst J, Tucker G. Medical and narrative approaches in psychiatry. 

8. Verhulst J, Tucker G. How many psychiatrists do we need? 

9. Verhulst J. Renteneurose en pseudo-identiteit. 

10. Verhulst J, Heiman J. An interactional approach to sexual dysfunctions. American Journal of Family Therapy. 1979;7:19-36.

11. Heiman J, Verhulst J, Heard-Davidson A. Childhood sexuality and adult sexual relationships: How are they connected by data and by theory? In: Bancroft J, Ed. 

 Bloomington, IN: Indiana University Press; 2003.

12. Bakker C, Gardner R, Jr, Koliatsos V, et al. 

13. Verhulst J, Gardner R, Sutton B, Beahrs J, et al. The social brain in clinical practice. 

14. Dunbar R. The social brain hypothesis. 

15. Kramer DA. History of family psychiatry: from the social reform era to the Primate Social Organ System. 

https://www.childpsych.theclinics.com/article/S1056-4993(15)00013-9/fulltext

16. Verhulst J, Kramer D, Swann AC, et al. 

The medical alliance: from placebo response to alliance effect

Articles

Johan Verhulst, MD, left this world exactly as he lived-with grace, honor, integrity, humor, love, humility, intellect, and a continuing interest in our ongoing professional conversations.

Remembering: A Gentleman and a Psychiatrist

When did human rights become negotiable in the US? When did human rights become a line item in a budget in the US? When did it become so difficult to simply do the right thing? Two recent newspaper articles portray how the seriously mentally ill have been systematically stripped of their human rights. By “human rights,” I mean the right to life and liberty.

 ran an update on Virginia State Senator and former gubernatorial candidate, 

. One year earlier, his 24-year-old son almost killed him-before killing himself. In “A father’s scars: for Va’s Creigh Deeds, tragedy brings unending questions,” Stephanie McCrummen

 tells the story of what life is like now for the senator.

He gets out of bed, where a piece of the shotgun he had taken apart in those last days of his son’s life is still hidden under the mattress. He goes outside to feed the animals, first the chickens in the yard and then the horses in the red-sided barn. He leads the blind thoroughbred outside with a bucket of feed, the same bucket he was holding when he saw Gus walking toward him-“Morning, Bud,” he said; “Morning,” Gus said, and began stabbing him-and then he goes back inside.

The dismantling and closure of the federal and state mental hospitals beginning in 1955 has resulted in an extreme shortage of programs and facilities for troubled persons such as Austin “Gus” Creeds to be evaluated; treated as long as necessary, ideally to a reasonable assurance of long-term stability; or kept indefinitely if necessary.

 That patients in some state mental hospitals were poorly treated, mistreated, or maltreated in the past does not mandate that a new public mental hospital system would do so.

Opponents of reinvigorating the public mental hospital system argue for community programs. However, community programs are always vulnerable to state and local budget cuts; have not been demonstrated to be consistently effective at early identification and management of young persons with emerging psychoses, especially if no crimes have been committed; and cannot ensure the safety of persons such as Gus Creeds and their potential victims-the victims often being people they love. Community programs are important but serve a different purpose in the continuum of care for the severely mentally ill.

The second article addresses where many of the seriously mentally ill are now found-if they have committed a crime: in our county jails, or for more serious crimes, in our state prisons. 

, a Madison, Wisconsin, weekly, published the following description of how life can be for the seriously mentally ill in a county jail-that life often being in solitary confinement.

In, “Boxed in: fighting for changes,” 

 calls his own jail “inhumane.” Steven Elbow describes the 4-day experience in solitary of Ian Olson, a 21-year-old college student at Macalester College. Ian was arrested for disorderly conduct after being disruptive and uncontrollable at a family gathering. This manic episode occurred because he had not taken his medication for bipolar disorder. It was the first time this had happened in 2 years of treatment. Judging from the date of his arrest, I am guessing that he discontinued his medications while studying for finals, or in conjunction with the end of his spring semester. This description of life in solitary confinement while psychotic is typical:

But he admits that on May 10, 2013, he was disruptive, insolent and uncontrollable, so much so that when he was taken to the jail, deputies abandoned the booking process and put him into Segregation Cell 1, a stark 6-by-9 foot room with a concrete bed, a thin green mattress, a steel toilet and sink, and a metal door with a small slot for food. The overhead light remained on 24 hours a day. On his first day, he flooded his cell by clogging the toilet, was placed in a “suicide smock,” and later strapped by the torso, ankles and wrists to a “violent prisoner restraint chair.” He didn’t eat, his water supply was cut off and he slept only sporadically.

The main difference between Ian Olson (college student) and Gus Deeds (senator’s son) is that Mr Olson had committed a crime, while Mr Deeds had not. Mr Olson lived, but endured 4 days of “inhumane treatment,” a euphemism for “torture.” This was caused by roadblocks for immediately admitting such patients to the barely functioning nearby state mental hospital. Such roadblocks are economically driven.

Mr Deeds died because of the same roadblocks. Time had run out on a court order remanding him to treatment at a state psychiatric hospital. There were no beds available at the time the order was obtained, and the legal limit in 2013 for holding someone while awaiting a bed, presumably someone dangerous to themselves or others, in North Carolina, was 6 hours. There are civil liberties reasons for limiting the length of psychiatric holds. However, dangerousness should trump civil liberties-especially when the currency is measured in hours-and psychosis with dangerousness is neither life nor liberty and is measured in lifetimes. If Mr Deeds had committed a crime, perhaps he could have gone to solitary confinement at the county jail-experienced inhumane treatment there-and lived.

Inhumane treatment of the mentally ill-is this really who we are?

Sheriff Dave Mahoney in Wisconsin belongs in the same discussion as Dorothea Dix, a serious reformer who campaigned for the treatment of the seriously mentally ill in hospitals rather than have them languish in jails and prisons-often in solitary confinement-sometimes for years, occasionally for decades.

, standing in one of the solitary confinement cells at the Dane County Jail, as he explains why we need to change the current system.

For every young adult from a socially and economically advantaged family, presumably capable of finding appropriate services, like the Deeds and Olson families appear to be, how many dozens, or hundreds, or perhaps thousands of such patients from disadvantaged families are being subjected to similar treatment and worse? Or living under a bridge suppressing their psychological pain with drugs and alcohol?

Real leaders do not compromise with right and wrong. Such leaders do not delay when “inhumane treatment” is occurring. Leaders educate constituents and advocate for justice. Leaders do the right thing oblivious to the electoral calculus. Leaders do not consider “inhumane treatment” to be a line item in a budget. A reinvigorated public mental hospital system would save the lives of people like Gus Creeds and the daily pain his parents still experience, as well as obviate the need to use solitary confinement for people like Ian Olson. Everyone has the right to life and liberty.

Note to readers: As with all of our blogs, the opinions expressed in this commentary are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. –

*Members of the Research Committee, Group for the Advancement of Psychiatry also include Dr John Beahrs, Emeritus Professor of Psychiatry, Oregon Health Sciences University, Portland; Dr Barbara Hale-Richlen, the Hale-Richlen Center for Psychiatry, Milwaukee; Dr David Keith, Professor of Psychiatry and Behavioral Sciences, Upstate Medical Center, SUNY, Syracuse, NY; Dr Patrick Malone, Psychology Associates, Chapel Hill, NC; Dr Anup Sharma, Resident in Psychiatry, University of Pennsylvania, Philadelphia; Dr Alan Swann, Professor of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston; and Dr Johan Verhulst, Emeritus Associate Professor of Psychiatry and Behavioral Sciences, University of Washington School of Medicine in Seattle, and Senior Advisor, The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University in Bloomington. Dr Margaret Cary, Assistant Professor, departments of psychiatry, and public health & preventive medicine, Oregon Health Sciences University, provided helpful comments on an earlier draft.

A father’s scars: for Va.’s Creigh Deeds, tragedy brings unending questions. 

 Kramer DA, Verhulst J. Guns, violence, and mental health: did we close the state mental hospitals prematurely? 

 Sacks O. The lost virtues of the asylum. 

 Elbow S. Boxed in: fighting for changes, Sheriff Dave Mahoney calls his own jail “inhumane.” 

 Rubinow DR. Out of sight, out of mind: mental illness behind bars. 

 Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bring back the asylum. 

 Kramer DA. Solitary confinement: it defines who we are. 

. July 18, 2014. http://www.psychiatrictimes.com/forensic-psychiatry/solitary-confinement-it-defines-who-we-are. Accessed February 6, 2015.

A look inside the Dane County Jail’s solitary confinement. 

November 4, 2014. Accessed February 13, 2015.

 Kramer DA. Jail proposal a defining issue for Dane County. 

When did human rights become negotiable in the US? A commentary on dismantling and closure of federal and state mental hospitals.

If It Were Physical Pain, It Would Be Called Torture: A Story of Two Young Men

Karen de SÃ¥, an investigative reporter for the 

 (CA), in four print articles and one 40-minute film produced by photojournalist Dai Sugano, has documented in impossible-to-ignore detail the systemic neglect of the neediest of needy children and adolescents in California, and very likely elsewhere. At a minimum, these most needy children include children with family difficulties, children in foster care, children who have experienced trauma (in multiple forms), children with a mental illness, children who are mostly underprivileged, often from minority backgrounds, and (unfortunately) children who are believed to be receiving adequate psychiatric treatment simply because they are receiving psychiatric medication. In the course of their research, the author and her colleagues reviewed ten years of data on psychotropic medication utilization in the California foster care system.

” Ms de SÃ¥ introduces the reader (and viewer) to several resilient young adults who, as children, were in the California foster care system, and who in that system had been treated with numerous psychotropic medications, mostly concurrently, until interventions by conscientious psychiatrists literally changed the course of their lives. The author and her colleagues spent an entire year developing this documentary. It is deserving of all of our attention. It is deserving, in my opinion, of a Pulitzer Prize.

These are the children about whom the Child Guidance Movement began in Chicago in 1909, and for whom the profession of Child and Adolescent Psychiatry was born. What happened to the ethos of the early 20

 century when reform minded citizens, judges, and mental health professionals insisted that our society be cognizant of the plight of such children and families? What happens now if we do nothing? Who are we if we let this continue?

 may have forced us to look up from our "Smart Phones" and glance in the mirror. Can we live with the reflection?   

"Drugging our Kids" is deserving of all of our attention, says this psychiatrist.

Underprivileged and Overmedicated

-Amendment VIII: Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.

New York State in Deal to Limit Inmate Isolation,

” Benjamin Weiser describes an agreement between the New York Civil Liberties Union and the New York Department of Corrections.

 of a suit filed in 2012, by the NYCLU, over the use of isolation for punitive purposes within New York State prisons.

Boxed In: The True Cost of Extreme Isolation in New York’s Prisons,

 Mr Weiser refers to the provisions in the new agreement as “sweeping reforms.”

Highlights of the New York State agreement

 include: 1) prohibiting the use of solitary confinement for prisoners under age 18 years; 2) prohibiting its use with pregnant women; and 3) limiting its use with developmentally disabled prisoners to a maximum of 30 days.

 The prohibition against solitary confinement for these “special” populations acknowledges that the practice is harmful to human beings. And imposing these limitations by category admits that, however dangerous the pregnant woman or the adolescent is judged to be, somehow the system will find a way to avoid implementing this administrative, ie, non-judicial, punishment.

Sweeping reforms? While it may be a relief to New Yorkers that pregnant women and high-school age prisoners will no longer to be subjected to solitary confinement, the reforms that the 

calls “sweeping” in fact allow this practice to continue for a minimum of 2 additional years.

 These “sweeping reforms” simply protect those who can’t protect themselves (teenagers, unborn children, and the developmentally disabled), those who almost anyone with a bit of common sense, humanity, or political astuteness would exempt. For the vast majority of prisoners, no such limitations have been imposed, nor will any be imposed in the near future because the agreement means “business as usual” until the next court hearing. In other words, it authorized 2 more years of being at risk for solitary confinement for most inmates. The NYCLU and the Federal District Court in Manhattan gave the state of New York exactly what it wanted, and what the 

Most of our society agrees that lost, stray, and unwanted animals should be treated in a caring and humane manner. Shouldn’t our fellow human beings be treated at least as well as our stray animals while “paying their debt to society?” Would anyone allow a stray or unwanted dog to be socially isolated for 5 months? I doubt it. But 5 months is the 

 for “extreme isolation” in New York State prisons-for human detainees!

, the new head of the Colorado prison system, the average length of solitary confinement in Colorado prisons is 23 months. Some inmates there spend as many as 20 years in solitary.

In corrections language, “solitary confinement” is referred to as “administrative segregation,” or (even more antiseptically) as “Ad Seg.”

 is also the former Sheriff of the county in which I have spent most of my professional life. He was recently appointed to replace Tom Clements as the Executive Director of the Colorado Department of Corrections. Mr Clements was 

 The murderer had been released from solitary confinement directly into the community shortly before the murder. The sad irony is that Mr Clements, described by Mr Raemisch to be “as courageous a reformer as they come,” had already reduced the number of prisoners in solitary confinement by half in just 2 years.

The governor of Colorado gave Mr Raemisch 3 directives when he appointed him:

• Limit or eliminate the use of solitary confinement for mentally ill inmates.

• Address the needs of those who have been in solitary for long periods.

• Reduce the number of offenders released directly from solitary back into their communities.

To begin to understand these goals, Mr Raemisch spent 20 hours in solitary confinement in the Colorado State Penitentiary. Raemisch described his experience in an 

 as “practically a blink” compared to the average stay.

 about his experience and recommendations.

Following his single night in solitary-but before the end of his self-imposed sentence of 20 hours-Mr Raemisch broke a promise to himself and asked a guard for the time. It was 11:10 AM. “I felt as if I’d been there for days. I sat with my mind. How long would it take before Ad Seg chipped that away? I don’t know, but I’m confident that it would be a battle I would lose.”

I do not know Mr Raemisch personally. Before his 

 Op-Ed, I knew of him only through his red campaign signs in our former neighborhood.

 I had voted for him for sheriff based on our local newspaper’s endorsement. He is a successful and seemingly dedicated individual. How many of us would spend a night in solitary, or a night as a patient in a public mental hospital, to better enable us do our jobs? I’ve never once considered doing such a thing. If Raemisch is “confident” that he would lose his mind in solitary confinement, it seems fair to assume that it’s a battle most of our patients would lose. And so would virtually every prisoner so treated.

A very benign interpretation of the disciplinary use of solitary confinement is that it began when we didn’t know any better. We now understand that the brain evolved as a social organ-an organ that facilitates social interactions of all types, analogous to the heart and the lungs evolving as cardiovascular-respiratory organs.

 Without social interaction, the mental human being ceases to exist, just as the physical human being ceases to exist if the cardiovascular system stops functioning. “I sat with my mind . . . it would be a battle I would lose.”

Perhaps this is naÃ¯ve, but I recall as a child, touring many of the original 13 colonies with my parents, seeing historic replicas of pillories where convicted criminals endured the humiliation of rotten tomatoes and vegetables being being thrown at them in their obviously defenseless position. This was later declared “cruel and unusual punishment.” At least that punishment was temporary. At least it was actually a social experience. It may have shamed and embarrassed, but it was social, and it was public. It was not an assault on the essence of the human brain and the brain’s emergent property of mind.

Although New York State had earlier banned the use of solitary confinement with seriously mentally ill prisoners, most states have not. 

, one of which is that estimates of the incidence of serious mental illness in prisoners range from 20% to 40% and growing.

 are prisoners with PTSD, major depression, bipolar disorder, and schizophrenia. What is the effect of any length of solitary confinement on persons with these disorders? Mr Raemisch, after 20 hours in solitary confinement, which he knew before hand would both be time-limited and could be terminated at any time, said it was a battle he “would lose.”

All state and federal prisoners have been convicted in a court of law and sentenced to these facilities. The sentence entails a loss of freedom and a loss of certain rights. But the right to be protected from 

 Solitary confinement for the overwhelming majority of prisoners is not ordered at sentencing. It is non-judicial. It is a second level of punishment wholly administered outside the judicial system. It is unrelated to due process, a trial by one’s peers, the assumption of innocence, the right to council, etc. Solitary confinement for most prisoners, in my opinion, is cruel and unusual punishment. Solitary confinement for prisoners with serious mental illness, in my opinion, is torture.

Most psychiatrists and other experts working with prison populations have expressed deep concern about the use of solitary confinement with seriously mentally ill prisoners, including excellent reviews by 

However, a recent study, flawed in my opinion,

 deserves comment as it appeared to show no harm associated with solitary confinement for inmates-regardless of whether they were diagnosed with mental illness.

 Coincidentally, it was conducted in Colorado where there is continuing commitment for reform, and at the same facility where Mr Raemisch spent 20 hours in voluntary “administrative segregation.” Furthermore, Dr Metzner and Mr Fellner were co-authors of this recent report, but neither was the lead author.

Study design for this problem is challenging. The logical comparison groups are fellow inmates: those with and without mental illness-subjected to solitary confinement or not. However, that imposes the confounding variable that all subjects are incarcerated whether or not subjected to solitary. Of the 302 inmates in the original study population, 55 either refused to participate or were removed from the study due to behavioral issues. Difficulties with determining subject motivation for participation, and perhaps the skewing of subject responses for the perceived benefit of the investigators cannot be measured.

Lastly, the only measure of psychological distress reported was the Brief Symptom Inventory,

 certainly not comparable to comprehensive psychological or psychiatric evaluations. Of course, no pre-incarceration studies were available either for comparison. Subjects with mental illness subjected to solitary had more difficulty at each measurement interval than their non-solitary comparison groups, but all groups showed diminished symptoms over the one-year duration of the study. The findings could [cynically] be used to argue that all patients could be kept in solitary confinement without concern for psychological harm.

Some detainees in the state and federal prisons have committed crimes that many of us can never forgive. But how we treat such people beyond the loss of freedom and certain rights is entirely about who we are as a society. It is not about them or what they did. It is about us.

The bottom line: solitary confinement is “cruel and unusual.” And solitary confinement for the seriously mentally ill is torture. We don’t subject stray dogs to solitary confinement––because we know it would be unethical. This issue defines who we are as a society. Are we comfortable with that identity? I hope not.

Additional resources from National Public Radio (NPR), 2006-2014

N.Y. Becomes Largest Prison System To Curb Solitary Confinement.

In U.S. Prisons, Thousands Spend Years in Isolation.

 NPR Special Series: Life in Solitary Confinement, July 26, 2006.

At Pelican Bay Prison, a Life in Solitary.

 NPR All Things Considered, Life in Solitary Confinement, Part I, July 26, 2006.

As Populations Swell, Prisons Rethink Supermax.

 NPR All Things Considered, Life in Solitary Confinement, Part II, July 27, 2006.

Making It on the Outside, After Decades in Solitary.

 NPR All Things Considered, Life in Solitary Confinement, Part III, July 28, 2006.

Solitary Confinement: Punishment or Cruelty?

 NPR All Things Considered, March 10, 2013.

Dr Kramer is Emeritus Clinical Professor of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. He is also Chair, Committee on Research, Group for the Advancement of Psychiatry; and a Distinguished Life Fellow, American Academy of Child & Adolescent Psychiatry. He writes a column for 

 “The Biological Roots of Child Psychiatry.”

1. Weiser B. New York State in deal to limit inmate isolation. 

 A1. February 20, 2014. Accessed May 15, 2014.

2. Secret M. New York State is sued over use of isolation in its prisons. 

. A36. December 7, 2012. Accessed May 15, 2014.

Boxed in: the true cost of extreme isolation in New York’s prisons.

4. Peoples v. Fischer, 11-CV-2694 (USDC SDNY, 2014).

. A25. February 21, 2014. Accessed May 29, 2014.

6. Crowley C. Hickenlooper: “A nightmare I couldn’t wake up from.” 

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7. Goode E. After 20 hours in solitary, Colorado’s prisons chief wins praise. 

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8. Elbow, S. Former Dane County sheriff Rick Raemisch spends a night in the hole. 

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How Monkeys See the World: Inside the Mind of Another Species.

10. Kramer DA. Commentary: gene-environment interplay in the context of genetics, epigenetics, and gene expression. 

Guns, violence, and mental health: did we close the state mental hospitals prematurely?

2013;30(6):34-25. Accessed July 18, 2014.

12. Kramer DA. Jails that masquerade as psychiatric hospitals. 

14. Metzner J. Evolving issues in correctional psychiatry. 

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15. Metzner JL, Fellner J. Solitary confinement and mental illness in US prisons: a challenge for medical ethics. 

16. O’Keefe M, Klebe KJ, Metzner J, et al. A longitudinal study of administrative segregation. 

Brief Symptom Inventory: Administration, Scoring, and Procedures Manual.

Detainees in state and federal prisons have committed crimes that many of us can never forgive. But how we treat such people beyond the loss of freedom and certain rights is entirely about who we are as a society. More in this commentary.

Solitary Confinement: It Defines Who We Are

And we believe ours is a civilized society.

description of Cook County Jail by Laura Sullivan of NPR

Cook County is one of many large county jails that masquerade as a public mental hospital. At least one-third of the 10,000 inmates at Cook County have serious mental health problems. At Cook County, the mentally ill do receive psychiatric care. There are wards for men and for women. The NPR story reports that these struggling men and women, having truly “hit bottom,” go so far as to commit minor crimes to cause their own incarceration. They are that desperate to maintain access to their necessary psychiatric medications. At least they are taking responsibility-in the only way they know how

In the eyes of many, the current societal approach to the treatment of psychiatric disorders cannot possibly be considered humane. More in this commentary.