Health and Solitary Confinement: Issues and Impact

How does isolation affect incarcerated individuals—and the broader society?

INCLUSIVITY AND DIVERSITY

Series Editor Frank A. Clark, MD

(This is the second part of a 2-part series. The first piece defines solitary confinement and discusses its history of use in jails and prisons.—Ed.)

In the first article in this series, I introduced solitary confinement (SC) and discussed its history of use (and misuse) in jails, prisons, and immigrant detention centers. In this second part, I will discuss the overall impact of SC and its effects on individuals and society.

What is the Health Impact of SC?

There is surmounting evidence that SC—with its cocktail of sensory deprivation and overload, social disconnection, and idleness—harms the mental and physical health of those exposed to it. Those without preexisting mental illness may experience a deterioration in mental health, and those with mental health conditions often decompensate and cycle from suicide watch to psychiatric hospital and back to SC.

Placing someone in an extreme environment like SC taxes the body and psyche, and often overwhelms a person’s capacity to cope. Isolation like SC is associated with a 26% increased risk of premature death, largely from a stress response that produces significant cortisol levels, increased blood pressure, and inflammation. Chronic stress damages the hippocampus which is associated with memory, spatial orientation, learning, and emotion processing, while increasing activity of the amygdala which mediates fear and anxiety.1-3

Individual responses to segregation vary. Some decompensate faster than others, and some are impacted more than others, but no one leaves unscathed. Possible complications within days are outlined in the Table.4-12 Furthermore, SC can be quite retraumatizing for individuals who have a history of trauma.

Some of these effects may persist after release from SC. In 2017, Stanford University’s Human Rights in Trauma Mental Health Lab released a consultative report detailing the mental health consequences following release from SC in California. The report stated that those who had been out of SC for an average of 14 months were endorsing “emotional suppression and dysregulation”; “significant alterations in cognition and perception”; “problems with attention, concentration, memory”; “pervasive hypervigilance, worry, nervousness”; “chronically feeling under threat or danger”; “sensory sensitivity”; “distress, anxiety, paranoia, irritability”; and “overwhelmed.” The report also stated that the majority of these individuals said they needed mental health care as a result of the psychological harm they experienced while in SC, but were hesitant to request mental health services in prison due to their distrust of the system.13

I have treated individuals in the community who continue to suffer from these social determinants of health (SDOH) years after their release from prison. SC is seen and experienced as a deliberate attempt and tool to break you. Every person I have spoken with who has been in SC has mentioned an intense fear of losing their sanity and of the tremendous energy it takes to not deteriorate into “madness.” Mr Albert Woodfox, who spent 43 years in SC in prison after he and 2 other Black Panther party members were accused of murdering a prison guard in 1972,has spoken of the fear he endured “adapting to the painfulness… There is a part of me that is gone. I had to sacrifice that part in order to survive.”14

Through his research conducting functional magnetic resonance imaging (fMRI) on individuals in social isolation, neuroscientist Matthew Lieberman, PhD, director of the UCLA Social Cognitive Neuroscience Laboratory, has found that the same neural and neurochemical processes that are caused by physical pain are invoked during social isolation.15-17 It is a painful existence.

Human connection is a universal essential basic human need.18 SC strains and breaks connections with families and friends, weakening one of the most important protective factors we know against suicide and one of the most vital ingredients for health. Human beings are social creatures. We define ourselves by our relationships to others. Research has shown that19:

“…depriving people of normal social contact and meaningful social interaction over long periods of time can damage or distort their social identities, destabilize their sense of self, and, for some, destroy their ability to function normally in free society… Prolonged social deprivation… is destabilizing in part because it deprives persons of the opportunity to ground their thoughts and emotions in a meaningful social context—to know what they feel and whether those feelings are appropriate… The human brain is literally ‘wired to connect’ to others… Social exclusion is not only ‘painful in itself,’ but also ‘undermines people’s sense of belonging, control, self-esteem, and meaningfulness, reduces prosocial behavior, and impairs self-regulation’… Social exclusion can result in… emotional numbing, reduced empathy, cognitive inflexibility, lethargy, and an absence of meaningful thought.”

It is, therefore, not surprising that more than 50% of suicides in carceral institutions occur in this setting.20 In 2014, 79% of suicides in California prisons occurred in isolation units.21 Additionally, individuals in SC have the highest rates of self-injurious behaviors.20,22

Who Gets Placed in SC?

While working in California prisons, I was told that individuals confined to SC “earned their way there” and that they were “the worst of the worst.” The reality is that this highly restrictive housing that was supposed to be used as a last resort after exhausting alternatives has become the management tool of choice for all sorts of disturbances and inconveniences. There is an extensive laundry list of possible nonviolent disciplinary infractions that could land individuals in SC, including disobeying an order, having an unauthorized extra piece of clothing or food, having too many stamps, refusing a cellie, talking back, indecent exposure, misusing medications, gambling, and being unsanitary. At a private detention center I reviewed in 2019, there were 16 detainees in SC for “engaging in or inciting a group demonstration” (ie, a hunger strike) to protest the conditions of their confinement.23

Ethnic group members who are impacted by racism and implicit biases, and deemed to be a potential threat even though they have not broken a rule or had a violent offense, are often placed in SC. Not only are people of color disproportionately represented in the criminal system—they are also placed in SC at much higher rates.24,25 Additionally, those who are vulnerable to victimization—such as the elderly; those with intellectual, mental, or physical disabilities; LGBTQ people; and those who have “snitched” on others—are sent to SC for their own protection, at a great cost. LGBTQ people are more likely to be placed in SC.26 Individuals with disabilities and members of other vulnerable groups need to be provided accommodations with equal access to all programs, services, and activities that are available in the general population and, not in essence, punished for their conditions or who they are. SC should not be a substitute for having adequate staffing, quality treatment, or trauma-informed practices.

According to a Department of Justice Bureau of Justice Statistics report from 2017, half of individuals in state prisons had either current “serious psychological distress” or a history of mental health problems.27 Those with mental illness often struggle to follow the rules of confinement, leading first to writeups and then to SC, the duration of which often gets extended with further troubles as the individuals decompensate while there. The 1995 federal class-action lawsuit, Madrid v Gomez, decided by Judge Thelton Henderson, found that Pelican Bay State Prison was unconstitutionally housing those with mental illness in security housing units, as it violates the Eighth Amendment’s ban on cruel and unusual punishment. Henderson wrote28:

“For these inmates, placing them in [the segregated housing unit] is the mental equivalent of putting an asthmatic in a place with little air to breathe. The risk is high enough, and the consequences serious enough that we have no hesitancy in finding that risk is plainly unreasonable.”

In 2015, Anthony Kennedy, former associate justice of the Supreme Court, reviewed the literature on SC causing mental illness and “criticized the widespread use of solitary confinement in American prisons… ‘Research still confirms what this court suggested over a century ago: Years on end of near-total isolation exacts a terrible price.”29,30 Unfortunately, despite these powerful condemning rulings against SC, across the country, individuals both with and without mental health conditions continue to be placed in SC, increasing their risk of bad health outcomes.

The fact that individuals may be sent to SC for so many potential nonviolent reasons creates a culture of fear and a breeding ground for injustices. Custodial officers have tremendous discretionary power to determine what constitutes a rule violation. “When you have very little oversight and little controls on systems of extreme punishment, what you see is discrimination, and animus works its way in,” said Amy Fettig, the senior staff counsel for the ACLU National Prison Project.31 Detained immigrants, especially, have even more limited or no recourse for unjust placement.

What Protections are in Place for SC?

Due to some recognition of the harsh, dehumanizing conditions of SC by prisons, jails, and detention center administrators, policies and regulations have been written to mitigate these harms. Some directives include pre-SC placement screening by a health care professional (usually an LVN or RN, possibly with some mental health training) who clears the individual for SC or not; daily wellness checks by a health care professional (unfortunately, a brief, nonconfidential cell-front interaction); custodial safety checks; weekly or monthly mental health visits for those identified with mental health conditions; periodic mental health visits with those not on the mental health caseload; mental health providers advocating for the transfer of patients who have decompensated from this placement; and weekly multidisciplinary meetings. Unfortunately, I have witnessed that, for a myriad of reasons, these mandates have not been followed, are inadequate, or have not provided the necessary relief.

Health care professionals should not be declaring anyone cleared for this type of high-risk containment, knowing what we know. To do so gives approval and legitimacy to the practice. First do no harm. According to the Physicians for Human Rights (PHR) dual loyalty guide32:

“doctors should not collude in moves to segregate or restrict the movement of prisoners except on purely medical grounds, and they should not certify a prisoner as being fit for disciplinary isolation or any other form of punishment… Doctors should not certify fitness for isolation.”

The National Commission on Correctional Health (NCCHC) 2016 SC position statement says something similar: “Health staff must not be involved in determining whether adults or juveniles are physically or psychologically able to be placed in isolation.”33

Final Words on Eliminating an SDOH

Recognizing the preventable harms from SC placement even with a few days, it is our clinical obligation to our patients and our social responsibility to all individuals incarcerated to challenge this practice. Some feel that it is not their job to call out human rights violations or injustices, some may feel powerless, and some may fear the real threat of retaliation if they speak up against policies or actions that harm patients. However, “individual practitioners should not have to wrestle alone with a prison practice that violates human rights norms. Their professional organizations should help them… organizations… should use their institutional authority to press for a nationwide rethinking of the use of isolation.”34

Although various organizations, including the NCCHC, the World Health Organization, PHR, the American Psychiatric Association, the American Public Health Association, the World Medical Association, the American Medical Association, and the United Nations, have written position statements—some stronger than others—regarding the detriments of SC, more needs to be done collectively to bring about change. As long as SC is an option, it will be used.

Considering that 95% of those incarcerated will be released back into the community, the fact that they will bring with them the negative health consequences of their confinement (any conditions or traumas they faced while incarcerated) should concern us all. It is also 3 times more expensive to house someone in SC than the general population, and SC is at odds with the goal of rehabilitation, or the facilitation of social reintegration.12

Social psychologist Craig Haney, PhD, has explained that “in order to survive the experience, many people must adapt to it in ways that deny fundamental aspects of their humanity: Solitary confinement is a socially pathological environment that forces long-term inhabitants to develop their own socially pathological adaptations in order to function and survive.”34

In a 2015 Washington Post op-ed, former US President Barack Obama wrote, “How can we subject prisoners to unnecessary solitary confinement, knowing its effects, and then expect them to return to our communities as whole people? It doesn’t make us safer. It’s an affront to our common humanity.”35

There is much evidence that SC promotes more harm than safety—as such, this experiment needs to be halted. More humane strategies that maintain institutional security while protecting human rights and health are urgently needed.

Dr McCall is a psychiatrist in Martinez, California.

References

1. Holt-Lunstad J, Smith TB, Baker M, et al. Loneliness and social isolation as risk factors for mortality: a meta-analytic reviewPerspect Psychol Sci. 2015;10(2):227-237.

2. Kim EJ, Pellman B, Kim JJ. Stress effects on the hippocampus: a critical reviewLearn Mem. 2015;22(9):411-416.

3. Blanco-Suarez E. The effects of solitary confinement on the brain. Psychology Today. February 27, 2019. Accessed February 20, 2022. https://www.psychologytoday.com/us/blog/brain-chemistry/201902/the-effects-solitary-confinement-the-brain

4. Ahalt C, Rothman A, Williams BA. Examining the role of healthcare professionals in the use of solitary confinementBMJ. 2017;359:j4657.

5. Ahalt C, Haney C, Rios S, et al. Reducing the use and impact of solitary confinement in correctionsInt J Prison Health. 2017;13(1):41-48.

6. Ahalt C, Williams B. Reforming solitary-confinement policy—heeding a presidential call to actionN Engl J Med. 2016;374(18):1704-1706.

7. Appelbaum KL. American psychiatry should join the call to abolish solitary confinementJ Am Acad Psychiatry Law. 2015;43(4):406-415.

8. Cloud DH, Drucker E, Browne A, Parsons J. Public health and solitary confinement in the United StatesAm J Public Health. 2015;105(1):18-26.

9. Gallagher S. The cruel and unusual phenomenology of solitary confinementFront Psychol. 2014;5:585.

10. Kupers TA. Prison Madness: The Mental Health Crisis Behind Bars and What We Must Do About It. Wiley, John & Sons; 1999.

11. Kupers TA. Solitary: The Inside Story of Supermax Isolation and How We Can Abolish It. University of California Press; 2017.

12. James K, Vanko E. The Impacts of Solitary Confinement. Vera Institute of Justice; 2021.

13. Brunner J, Joseff K, Matlow R, et al. Mental health consequences following release from long-term solitary confinement in California: consultative report prepared for the Center for Constitutional Rights. Human Rights in Trauma Mental Health Lab, Stanford University; 2017.

14. Aviv R. How Albert Woodfox survived solitary. The New Yorker. January 8, 2017. Accessed February 20, 2022. https://www.newyorker.com/magazine/2017/01/16/how-albert-woodfox-survived-solitary?utm_source=onsite-share&utm_medium=email&utm_campaign=onsite-share&utm_brand=the-new-yorker

15. Jones OD, Marois R, Farah MJ, Greely HT. Law and neuroscienceJ Neurosci. 2013;33(45):17624-17630.

16. Morse SJ. Criminal law and common sense: an essay on the perils and promise of neuroscience. Marquette Law Review. 2015;99(1):39-74.

17. Murphy E. Neuroscience and the civil/criminal Daubert divide. Fordham Law Review. 2016;85(2):619-629.

18. Allen KA, Gray DL, Baumeister RF, Leary MR. The need to belong: a deep dive into the origins, implications, and future of a foundational construct [published online ahead of print, 2021 Aug 31]. Educ Psychol Rev. 2021;1-24.

19. Haney C. Restricting the use of solitary confinement. Annual Review of Criminology. 2018;1(1):285-310.

20. Kaba F, Lewis A, Glowa-Kollisch S, et al. Solitary confinement and risk of self-harm among jail inmatesAm J Public Health. 2014;104(3):442-447.

21. Reiter K. 23/7: Pelican Bay Prison and the Rise of Long-Term Solitary Confinement. Yale University Press; 2016.

22. Lantigua-Williams J. The link between race and solitary confinement. The Atlantic. December 5, 2016. Accessed February 20, 2022. https://www.scribd.com/article/333333192/The-Link-Between-Race-And-Solitary-Confinement

23. The California Department of Justice’s Review of Immigration Detention in California. Office of the Attorney General, California Department of Justice; 2021.

24. Flagg A, Tatusian A, Thompson C. Who’s in solitary confinement? The Marshall Project. November 30, 2016. Accessed February 20, 2022. https://www.themarshallproject.org/2016/11/30/a-new-report-gives-the-most-detailed-breakdown-yet-of-how-isolation-is-used-in-u-s-prisons

25. Beck AJ. Use of restrictive housing in U.S. prisons and jails, 2011-12. United States Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2015.

26. Bronson J, Berzofsky M. Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. United States Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; 2017.

27. Madrid v Gomez, 889 F. Supp. 1146, (N.D. California 1995).

28. Davis v Ayala, 135 S. Ct. 2187, 2208-2210 (2015).

29. Ford M. Justice Kennedy denounces solitary confinement. The Atlantic. June 18, 2015. Accessed February 20, 2022. https://www.theatlantic.com/politics/archive/2015/06/kalief-browder-justice-kennedy-solitary-confinement/396320/

30. Eichelberger E. How racist is solitary confinement? The Intercept. July 16, 2015. Accessed February 20, 2022. https://theintercept.com/2015/07/16/rikers-study-black-inmates-250-percent-likely-enter-solitary/

31. Dual Loyalty, Global. Dual loyalty and human rights in health professional practice: proposed guidelines and institutional mechanisms. Physicians for Human Rights. March 1, 2003.

32. Solitary confinement (isolation). National Commission on Correctional Health Care. April 10, 2016. Accessed February 20, 2022. https://www.ncchc.org/solitary-confinement

33. Metzner JL, Fellner J. Solitary confinement and mental illness in U.S. prisons: a challenge for medical ethicsJ Am Acad Psychiatry Law. 2010;38(1):104-108.

34. Haney C. The psychological effects of solitary confinement: a systematic critique. Crime and Justice. 2018;47.

35. Obama B. Barack Obama: Why we must rethink solitary confinement. The Washington Post. January 25, 2016. Accessed February 20, 2022. https://www.washingtonpost.com/opinions/barack-obama-why-we-must-rethink-solitary-confinement/2016/01/25/29a361f2-c384-11e5-8965-0607e0e265ce_story.html